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DISEASES    OF    THE    PHARYNX   AND 
LARYNX 


TRANSLATOR'S    PREFACE 

It  is  not  necessary  to  say  anything  by  way  of  introduction 
of  Dr.  E.  J.  Moure  to  the  medical  profession  of  this  country. 
He  is  well  known  by  his  writings  in  the  field  of  medicine  he 
has  made  his  own.  His  work,  however,  on  '  Diseases  of  the 
Pharynx  and  Larynx  '  is  not  so  familiar  to  British  readers  as 
it  is  on  the  Continent  ;  hence  the  appearance  of  the  present 
translation.  It  has  been  the  endeavour  of  the  translator  in 
making  the  abridgment  to  omit  no  essentials,  and  to  follow 
the  author's  language  as  closely  as  possible,  and  he  has 
refrained  from  any  alteration  of  the  author's  style  and  from 
any  comment  on  his  opinions.  He  trusts  the  volume  may 
be  of  use  as  a  small  manual  to  young  practitioners  and 
senior  students. 

Edinburgh,  1909. 


Digitized  by  tine  Internet  Arciiive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/elementarypractiOOmour 


■     AUTHOR^S    PREFACE 

In  presenting  to  the  medical  profession  this  work  on  the 
'  Diseases  of  the  Pharynx  and  Lar3-nx,'  which  constitutes  in 
a  way  a  second  edition  of  my  lectures  on  these  diseases 
(i8go),  and  to  which  I  have  added  the  patholog}-  of  the 
tonsils,  the  soft  palate,  the  phar}-nx,  and  the  hngual  tonsil, 
I  have  endeavoured,  above  all,  to  write  a  book  complete 
enough  to  furnish  the  general  practitioner  with  useful 
information  regarding  these  affections,  with  respect  to 
which  he  is  not  always  conversant. 

Thanks  to  our  methods  of  investigation,  as  well  as  to  the 
introduction  of  bacteriology  into  the  clinical  study  of  throat 
diseases,  we  are  nov-  in  a  better  position  to  understand  the 
pathology  of  the  phar}-nx.  The  subject  of  therapeutics  has 
also  been  advanced  by  the  recent  progress  of  special  surgery. 
I  have,  moreover,  deemed  it  expedient  to  adopt  a  classihca- 
tion  a  little  different  to  that  adopted  by  the  majority  of 
authors. 

Among  the  iniiammatory  conditions  I  have  included  a 
certain  number  of  diseased  conditions  little  known,  or  at 
least  little  studied,  till  recent  years,  and  which  have  not 
found  a  place  in  the  most  recent  treatises  and  classical 
manuals.  Such  conditions  are  :  erj-thematous  angina,  er}- 
thema  polymorphia,  pemphigus,  and  acute  ulcerative  lacunar 
tonsillitis,  which  I  have  differentiated  from  ulcerative  mem- 
branous tonsillitis,  with  which  it  is  so  often  confused. 

As  regards  tonsillar  abscesses,  I  have  adopted  a  classifica- 
tion based  upon  the  origin  of  these  suppurative  processes, 


viii  AUTHOR'S  PREFACE 

and,  above  all,  upon  the  history  0/ their  duration.  From  these 
chnical  and  anatomical  observations  a  special  plan  of  treat- 
ment has  been  evolved,  to  which  I  have  referred  in  passing. 
After  the  anginous  affections  proper  have  been  discussed, 
I  have  passed  on  to  the  acute  and  chronic  affections  of  the 
lingual  tonsil,  together  with  the  tumours  of  that  region  ; 
furthermore.  I  have  described  in  a  special  chapter  simple 
degenerations  of  that  gland,  and  especially  lingual  goitre 
and  cysts  of  Bochdalek's  canal. 

On  the  other  hand,  I  have  not  thought  it  necessary  to 
burden  this  book  with  a  description  of  the  anginse  sympto- 
matic of  rheumatism,  scarlet  fever,  German  measles,  roseola, 
measles,  influenza,  erj'sipelas,  small-pox,  chicken-pox,  and 
mumps. 

These  affections,  it  seems  to  me,  are  best  treated  in  books 
on  general  medicine,  where  symptomatic  conditions  find 
a  better  place  than  in  a  special  work.  In  fact,  the  con- 
ditions which  accompany  these  symptomatic  affections  of 
the  throat  are  in  themselves  sufficient  to  make  a  diagnosis, 
and  as  regards  their  treatment  there  is  nothing  special  to 
note. 

Scarlatinal  angina,  perhaps,  alone  merits  a  special  descrip- 
tion, and  here  I  am  obliged  to  point  out  the  differential 
diagnosis  between  simple  infectious  anginse  and  those  due 
to  the  lesions  of  scarlet  fever  in  the  pharynx. 

In  the  second  part,  which  is  devoted  to  the  diseases  of  the 
larynx,  I  have  described  the  methods  which  we  make  use  of 
in  modern  examination.  In  this  part  I  have  described 
Kirstein's  direct  method  of  tracheoscopy  and  Killian's 
tracheo  -  bronchoscopy.  In  the  chapters  devoted  to  the 
pathology  of  the  larynx,  I  have  included  the  study  of 
influenzal  laryngitis,  spasmodic  laryngitis,  and  rheumatic 
laryngitis.  Likewise  I  have  attempted  to  describe,  not  only 
the    special    operations  per  vias  naturales,  but    also   a  large 


AUTHOR'S  PREFACE  ix 

number  of  the  operations  which  have  to  be  performed  from 
without.  I  have  attempted,  as  far  as  possible,  to  describe 
the  rarer  and  more  classical  diseases  of  the  pharynx  and  of 
the  larynx,  along  with  the  instruments  most  commonly  used 
in  their  treatment. 

Thanks  to  my  most  excellent  publisher,  M.  Octave  Doin, 
I  have  been  permitted  to  insert  coloured  plates,  by  means 
of  which  I  am  better  able  to  demonstrate  different  points  in 
the  special  pathology,  often  so  difficult  correctly  to  describe. 

On  the  other  hand,  I  have  not  thought  it  necessary  to 
devote  a  special  chapter  either  to  intubation,  which  is  very 
well  described  in  special  works,  or  to  perichondritic  affec- 
tions, as  I  do  not  consider  the  latter  to  exist  as  primary  and 
truly  idiopathic  lesions.  Cartilaginous  lesions  are  nearly 
always  secondary.  I  have  described  the  perichondritic  affec- 
tions along  with  each  of  the  diseases,  in  the  course  of  which 
it  is  almost  always  the  rule  to  meet  with  alterations  in  the 
frame-work  of  the  larynx. 

Finally,  in  this  work,  I  have  tried  above  all  to  show  the 
result  of  my  practice  during  the  last  twenty-five  years.  If 
my  views  appear  at  times  contrary  to  those  generally  laid 
down  in  classical  works,  I  have  the  conscious  feeling  that 
they  are  the  result  of  my  clinical  observations.  The  same 
may  be  said  of  the  therapeutics.  Nearly  everything  I  have 
described  is  the  outcome  of  my  own  experience  rather  than 
the  theoretical  deduction  from  this  or  that  special  pathology. 

E.  J.  MOURE. 
Bordeaux. 


CONTENTS 


PART  I 

ANATOMY  AND  PATHOLOGY  OF  THE  PHARYNGEAL 

CAVITY 


CHAPTER  I 

THE    ANATOMY    OF    THE    PHARYNGEAL    CAVITY 

CHAPTER    II 
PATHOLOGY    OF    THE    PHARYNX 

CHAPTER  III 

PATHOLOGY    OF    THE    LINGUAL    TONSIL    - 

CHAPTER  IV 

PATHOLOGY    OF    THE    SOFT    PALATE 

CHAPTER  V 

DISEASES    OF    THE    PHARYNX 


PAGE 

I 


86 


99 


PART  II 
THE    LARYNX 

CHAPTER  I 

EXAMINATION    OF    THE    LARYNX    AND    OF    THE    TRACHEA  -       151 

CHAPTER    II 
DISEASES    AND    TRAUMATISMS    OF    THE    LARYNX  -  169-399 


INDEX    - 


400 


ELEMENTARY    AND    PRACTICAL 

TREATISE     ON     DISEASES     OF    THE 

PHARYNX    AND    LARYNX 

PART    I 

ANATOMY    AND    PATHOLOGY    OF    THE    PHARYNGEAL 

CAVITY 

CHAPTER  I 

THE  ANATOMY  OF  THE  PHARYNGEAL  CAVITY 

From  an  anatomical  point  of  view  we  may  consider  the 
pharynx  as  belonging  to  the  buccal  cavity  and  to  the 
entrance  to  the  digestive  tract.  It  is  bounded  in  front  by 
the  soft  palate  with  its  annexa,  and  by  the  tonsils.  The 
pharynx  proper  forms  the  posterior  wall  attached  to  the 
vertebral  column,  while  superiorly  it  is  limited  by  an 
imaginary  plane  passing  backwards  through  the  base  of  the 
uvula.  The  inferior  boundary  extends  in  front  from  the  base 
of  the  tongue,  while  behind  and  on  a  deeper  plane  it  is 
formed  by  the  epiglottis,  the  aryepiglottic  folds,  the  arytenoid 
region,  and  the  œsophageal  opening.  Posteriorly  the  wall 
of  the  pharynx  is  in  contact  with  the  vertebral  column. 

Soft  Palate,  with  its  Pillars. 

The  soft  palate  is  a  musculo-membranous  septum  stretch- 
ing backwards,  without  any  well-marked  line  of  demarcation, 
from  the  osseous  palate.  Being  essentially  mobile  and 
contractile,  this  structure,  at  first  horizontal,  afterwards  bends 

I 


2  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

backwards,  becoming  almost  vertical,  and  forming  a  regular 
curve.     It  has  two  surfaces  and  four  borders. 

The  antero-inferior  or  buccal  surface  is  concave,  smooth, 
and  of  a  pink  colour,  like  that  of  the  whole  buccal  cavity. 
The  posterior  or  nasal  surface  is,  on  the  contrary,  convex, 
paler  in  colour,  and  rough.  The  anterior  border  is  con- 
tinuous with  the  posterior  palatal  arch  ;  the  lateral  borders 
extend  into  the  neighbouring  regions.  The  inferior  free 
border,  which  is  rather  thin,  presents  mesially  a  conical, 
elongated  projection — the  uvula — which  varies  in  length 
from  10  to  15  millimetres.  Four  mucous  folds  spring  from 
its  base — two  anterior  and  two  posterior — which  divide  as 
they  proceed.  The  first  two  form  the  anterior  pillars  of  the 
soft  palate,  and  end  laterally  at  the  base  of  the  tongue, 
almost  on  a  level  with  the  anterior  extremity  of  the 
lingual  V. 

The  posterior  pillars  diverge  backwards  towards  the  lateral 
walls  of  the  pharynx,  and  blend  with  them.  These  four 
pillars  form  along  with  the  uvula  two  arches,  whose  internal 
border,  limited  by  the  uvula,  does  not  descend  so  low  as  the 
others.  Between  the  pillars  and  on  the  lateral  walls  are 
two  fairly  deep  recesses,  known  as  the  tonsillar  fossae, 
in  which  the  tonsils  are  lodged. 

The  soft  palate  is  composed  of  a  quadrilateral  aponeurosis, 
which  is  attached  by  its  anterior  border  behind  the  vault 
of  the  hard  palate,  and  blending  laterally  with  the  tendon 
of  the  tensor  palati,  is  carried  backwards  into  the  muscular 
fasciculus  of  the  membranous  palate. 

The  muscles  of  the  soft  palate  consist  of  five  pairs  : 

1.  The  azygos  uvulae,  which  is  composed  of  a  small 
cylindrical  bundle  of  fibres,  arises  anteriorly  from  the  pala- 
tine aponeurosis  behind  the  posterior  nasal  spine,  and  is 
carried  downwards  and  backwards  to  the  top  of  the  uvula, 
in  which  it  ends.  These  two  symmetrical  muscles  are 
continuous  with  each  other,  and  were  formerly  regarded  as 
a  single  median  muscle. 

2.  The  levator  palati  is  attached  to  the  inferior  surface 
of  the  petrous  portion  of  the  temporal  bone  in  front  of  the 


THE  ANATOMY  OF  THE  PHARYNGEAL  CAVITY  3 

carotid  canal.  Its  fibres  are  carried  downwards  and  inwards, 
and  spread  out  in  a  fan-shaped  manner  over  the  posterior 
surface  of  the  soft  palate.  This  muscle  on  contraction  raises 
the  soft  palate,  and  constricts  the  Eustachian  orifice. 

3.  The  tensor  pa  I  at  i  arises  from  the  superior  surface 
of  the  internal  border  of  the  base  of  the  pterygoid  apophysis 
on  a  portion  of  the  great  wing  of  the  sphenoid,  and  on  the 
antero-external  walls  of  the  Eustachian  tube.  The  fibres 
are  carried  downwards,  following  the  internal  wing  of  the 
pterygoid  apophysis,  and  bend  over  the  hook  of  this  bone, 
terminating  by  spreading  out  over  the  inferior  surface  of  the 
soft  palate.  This  muscle  is  principally  concerned  as  a  tensor 
of  the  soft  palate  and  as  a  dilator  of  the  tube. 

4.  The  palato-pharyngei  are  situated  in  the  substance 
of  the  posterior  pillar,  and  follow  exactly  the  same  direction. 
One  of  the  accessory  fasciculi,  however  (the  salpingo-pharyn- 
geus),  comes  from  the  fibro-cartilaginous  portion  of  the  tube, 
whose  orifice  it  dilates.  This  muscle  serves  also  to  raise 
the  pharynx  and  larynx,  and  helps  to  narrow  the  faucial 
isthmus. 

5.  Finally,  the  palato-glossi  are  situated  in  the  sub- 
stance of  the  anterior  pillar. 

Mucous  Membrane. — All  the  pharynx  is  covered  with 
mucous  membrane,  which  is  a  continuation  of  that  lining 
the  mouth.  Like  the  latter,  it  is  composed  at  its  anterior 
part  of  stratified  squamous  epithelium.  The  posterior  part, 
which,  on  the  other  hand,  is  a  continuation  of  the  nasal 
cavity,  is  lined  at  its  superior  part  with  cylindrical  epithelium. 
It.  becomes  gradually  stratified,  as  it  approaches  the  free  or 
inferior  border. 

Glands. — The  soft  palate  is  very  rich  in  glands,  which 
are  distributed  over  its  two  surfaces.  It  pre-eminently  shows 
clusters  of  glands  analogous  to  those  of  the  cheeks  and  lips. 
They  are  connected  by  a  submucous  connective  tissue,  which 
is  rather  dense  on  its  inferior  but  looser  on  its  superior 
surface.  It  is  most  free  at  the  level  of  the  uvula,  and  it  is 
on  that  account  that  this  organ  has  such  a  marked  tendency 
to  swell. 

I — 2 


DISEASES  OF  THE  PHARYNX  AXD  LARYNX 


Vessels. — The  arteries  of  the  soft  palate  are  derived 
from — (ij  the  superior  palatine,  a  branch  of  the  internal 
maxillary — it  follows  the  posterior  palatine  groove  ;  (2)  the 
inferior  palatine,  a  branch  of  the  facial  ;  (3)  the  inferior 
pharyngeal,  which  is  distributed  mainly  over  the  posterior 
pillars. 

iA  J    J  \ 


Fig.   I, 

I,  Motor  nucleus  of  the  trigeminal  ;  2,  nucleus  common  to  the  facial  and  the 
oculo-motor  ;  3,  facial  nucleus;  4,  nucleus  of  the  glosso-pharj'ngeal  ; 
5,  nucleus  of  the  hypoglossal  ;  6,  origin  of  the  pneumogastric  ;  7,  bulbar 
origins  of  the  spinal  ;  8,  medullar}^  roots  of  the  spinal  ;  9,  the  middle 
peduncles  of  the  cerebellum;  10,  plexiform  ganglion;  11,  the  external 
branch  of  the  spinal  supplying  the  trapezius  and  the  sterno-mastoid  ; 
12,  the  pneumogastric  and  the  internal  branch  of  the  spinal  ;  13,  inferior 
peduncles  of  the  cerebellum  ;   14,  superior  peduncles  of  the  cerebellum. 

The  superior  veins  anastomose  with  the  inferior  of  the 
pituitary  membrane,  and  with  them  open  into  the  venous 
plexus  of  the  zygomatic  fossae.  The  inferior  veins,  which  are 
much  more  important,  first  appear  in  the  lateral  parts  of  the 
soft  palate,  Vv'here  thev  unite  with  the  tonsillar  veins,  or  with 


THE  ANATOMY  OF  THE  PHARYNGEAL  CAVITY  5 

those  at  the  base  of  the  tongue.  Like  the  latter,  they  flow 
into  the  internal  jugular,  or  into  one  of  its  tributaries. 

The  lymphatics  form  a  very  important  plexus,  especially 
at  the  base  of  the  soft  palate,  and  this  Sappey  has  compared 
to  that  on  the  dorsum  of  the  tongue.  These  vessels  flow 
into  the  deep  glands  of  the  neck. 

Motor  Nerves. — Up  to  the  present  it  has  been  held,  that 
the  azygos  uvulae  and  the  levator  palati  are  innervated  by  the 
posterior  palatine  nerve,  which,  springing  from  the  spheno- 
palatine ganglion,  receives  its  motor  branch  from  the  Vidian 
nerve,  and  this  in  its  turn  receives  its  motor  branch  from  the 
great  superficial  petrosal,  a  branch  of  the  facial.  The  tensor 
palati  may  be  innervated  by  a  branch  from  the  otic  ganglion, 
which  receives  its  motor  branch  from  the  small  superficial 
petrosal,  likewise  a  branch  of  the  facial.  The  palato- 
pharyngei  alone  receive  their  nervous  supply  from  the 
pharyngeal  plexus. 

Recently  Dr.  Lermoyez  has  demonstrated  from  anatomico- 
pathological  researches  what  the  author  likewise  has  seen — • 
that  the  muscles  of  the  soft  palate  receive  their  motor  supply 
from  the  spinal  accessory. 

On  leaving  the  bulb,  the  nerve-roots  forming  the  internal 
spinal  branch  blend  with  the  pneumogastric  in  the  plexi- 
form  ganglion,  while  the  external  branch  runs  towards  the 
trapezius  and  the  sterno-cleido-mastoid.  From  the  plexi- 
form  ganglion  the  internal  spinal  branch  descends  as  the 
pharyngeal  branch,  to  innervate  the  whole  of  the  muscles  of 
the  soft  palate. 

The  sensory  nerves  are  supplied  by  the  spheno-palatine 
ganglia. 

Uvula. 

This  organ  varies  in  form  in  different  individuals.  It  is 
usually  cone-shaped,  the  apex  pointed,  and  its  base  broaden- 
ing where  it  blends  with  the  anterior  pillars.  The  apex  is 
sometimes  rounded,  and  occasionally  it  is  found  shrivelled 
up  on  itself,  becoming  hammer-shaped,  and  giving  an  appear- 
ance as  if  it  were  the  seat  of  cicatricial  contraction,  resulting 


6  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

from  deep  cauterization.  Frequently  it  is  voluminous  and 
oblong,  while  it  is  not  uncommon  to  find  it  bifid,  varying  in 
extent  from  an  undulation  in  the  middle  line  to  a  complete 
separation  up  to  its  base.  The  mucous  membrane  is 
bound  tc  the  underlying  tissue  by  a  very  loose  cellular  tissue, 
which  explains  the  considerable  œdematous  infiltrations  that 
take  place  in  this  situation. 


Tonsils. 

The  tonsils  are  situated  in  the  hollows  known  as  the  tonsillar 
fossae.  They  resemble  a  half  walnut  in  shape,  the  convex 
part  being  directed  towards  the  mouth.  The  dimensions 
and  shape  vary  considerably  in  different  individuals.  Each 
tonsil  presents  two  surfaces  and  two  extremities.  The  free 
internal  surface  is  directed  inwards  towards  that  of  the  oppo- 
site side,  and  is  studded  over  in  an  irregular  manner  with  a 
great  number  of  apertures — the  crj^pts.  This  gland  has  some- 
times a  smooth,  even,  and  rounded  surface,  but  at  other  times 
it  is  vertically  elongated,  and  occasionally  it  may  appear  as  if 
it  were  made  up  of  several  masses,  imperfectly  united  and 
separated  by  deep  fissures,  generally  running  in  an  antero- 
posterior direction.  The  crj-pts  lead  into  sinuous  cavities, 
which  may  or  may  not  communicate  with  each  other,  and 
which  give  the  tonsils  a  sponge-like  structure.  The  secre- 
tions which  accumulate  in  these  cavities  have  not  a  ready 
egress,  and  it  is  to  this  special  conformation  that  we 
attribute  the  occurrence  of  certain  infections  in  this 
region. 

A  little  beyond  this  is  the  maxillo-pharyngeal  space,  in 
which  lies  the  vasculo-nervous  bundle,  which  includes  the 
carotid,  the  internal  jugular,  the  pneumogastric,  etc.  The 
internal  carotid  lies  against  the  external  pharyngeal  wall, 
and  is  separated  from  the  tonsil  by  the  entire  substance  of 
this  structure — a  distance  of  from  20  to  25  millimetres. 

The  superior  extremity  corresponds  to  the  divergence  of 
the  pillars  of  the  soft  palate.  Occasionally  we  see  groups  of 
follicular  masses  situated  on  the  arch  of  the  posterior  pillar, 


THE  ANATOMY  OF  THE  PHARYNGEAL  CAVITY  7 

which  look  Hke  an  extension  of  the  tonsil.  At  the  upper 
part  there  are  one  or  more  deep  crypts,  hidden  behind  the 
anterior  pillar.  Pathologically  it  is  important  to  note  this 
fact,  because  these  recesses  form  a  point  of  election  for 
certain  affections  in  this  region. 

In  1897  Killian  and  in  i8g8  Patterson  both  drew  atten- 
tion to  this  region,  called  by  the  former  the  superior  angle 
of  the  palatine  tonsil,  and  by  the  latter  the  supratonsillar 
fossa. 

Inferiorh'  the  tonsil  becomes  merged  in  the  border  of 
the  tongue,  blending  with  those  closed  follicles  which  are 
scattered  about  at  this  level,  and  which  are  known  as  the 
lingual  tonsil.  The  writer  has  observed  at  this  level  some 
deep  crypts,  which  open  imperfectly  on  the  surface  owing  to 
the  anterior  pillar  and  the  lateral  surface  of  the  base  of 
the  tongue  meeting  at  a  dihedral  angle.  This  explains  the 
occurrence  of  certain  infections  occupying  the  lower  part  of 
the  tonsil  towards  the  lateral  region  of  the  lingual  tonsil. 

Structure  of  the  Tonsil. — The  tonsillar  epithelium 
is,  like  that  of  the  neighbouring  regions,  pavemented  and 
stratified.  The  tonsil  itself  is  composed  of  adenoid  tissue — 
that  is  to  say,  of  a  series  of  closed  follicles,  among  which 
the  connective  elements  penetrate  from  the  submucosa.  In 
the  latter  are  some  acinous  glands  which  open  into  the  in- 
terior of  the  crypts. 

Vessels  and  Nerves. — The  arteries  come  from  the 
lingual,  the  inferior  pharyngeal,  and  the  superior  and  in- 
ferior palatines  ;  they  spread  out  and  ramify  in  the  tonsillar 
substance  among  the  follicles,  penetrating  even  their  in- 
terior. 

The  veins  are  placed  outside.  They  form  a  venous  plexus 
on  the  external  wall  of  the  tonsil,  and  this  is  worthy  of  note, 
as  it  explains  certain  haemorrhages,  which  sometimes  take 
place  after  section  of  these  glands.  The  author,  however, 
has  always  found,  on  examination  by  a  strong  light,  that  the 
blood  comes  from  an  arterial  rather  than  from  a  venous 
source. 

The  lymphatics  join  with   those    of  the    dorsum  of  the 


8  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

tongue,  and  lead  into  the  lymphatic  glands  at  the  angle  of 
the  jaw. 

The  nerves  come  from  the  lingual  and  glosso-pharyngeal. 


Pharynx. 

The    pharynx    extends    from    the    basilar    process    of    the 
occipital  to  the  fourth  or  fifth   cervical  vertebra.      It  is  an 


Fig.   2. — Diagrammatic  Horizontal  Section   of  the  Retropharyngeal 

Space  (Escat). 

vc,  Cervical  vertebra  ;  tv,  vertebral  foramen  ;  av,  vertebral  arter}-  ;  7)!fv,  pre- 
vertebral muscles;  gyp,  retropharyngeal  ganglion;  erp,  retrophar3-ngeal 
space  ;  app,  prevertebral  aponeurosis  ;  pg,  pneumogastric  ;  /,  jugular  ; 
c,  carotid  ;  gip,  lateral  pharyngeal  ganglion  ;  ap!,  lateral  aponeurosis  ; 
tf,  fibrous  laj-er. 

irregular  canal,  broader  above  than  below,  and  has  a  quadri- 
lateral appearance,  with  rounded  corners.  It  glides  on  the 
vertebral  column,  and  thus  allows  the  movements  necessary 
for  deglutition  and  respiration. 

It  is  attached  posteriorly  to  the  aponeurosis  of  the  pre- 


THE  ANATOMY  OF  THE  PHARYNGEAL  CAVITY  9 

vertebral  muscles  ;  laterally  to  the  carotid  and  internal 
jugular,  with  their  accompanying  nerves  ;  anteriorly  to  the 
posterior  nares,  the  soft  palate,  the  faucial  isthmus,  the  base 
of  the  tongue  and  the  epiglottis  ;  and  inferiorly  to  the  posterior 
surface  of  the  arytenoid  region,  to  the  aryepiglottic  folds, 
and  to  the  oesophageal  opening. 

The  buccal  pharynx  is  bounded  superiorly  by  a  plane 
passing  on  a  level  through  the  uvula,  and  inferiorly  by 
another  plane  traversing  the  posterior  extremity  of  the  great 
cornu  of  the  hyoid.  In  the  same  manner,  the  incomplete 
anterior  surface  is  formed  by  the  uvula  and  the  base  of  the 
tongue  with  the  aryepiglottic  folds  as  its  inferior  boundary. 
The  laryngeal  portion  of  the  pharynx  occupies  the  space 
between  the  hyoid  bone  above  and  the  superior  border  of  the 
cricoid  cartilage  below.  In  the  middle  is  the  epiglottis  with 
its  glosso-  and  ary-epiglottic  folds,  the  inferior  wall  being 
formed  by  the  oesophageal  orifice.  The  length  of  this  canal 
is  from  4  to  4^  centimetres. 

The  pharyngeal  muscles  are  composed  of  three  constrictors 
— the  superior,  the  middle,  and  the  inferior  ;  to  which  must 
be  added  the  two  elevators — the  palato-pharyngeus  and  the 
stylo-pharyngeus,  the  latter  being  a  long,  narrow,  straight 
muscle  springing  from  the  inner  sides  of  the  base  of  the 
styloid  process,  and  passing  obliquely  downwards  and  inwards 
on  to  the  outer  wall  of  the  pharynx. 

Mucous  Membrane. — The  mucous  membrane  of  the 
pharynx  is  lined  externally  with  a  fibrous  layer,  which  is 
continuous  with  that  of  the  oesophagus.  It  is  covered  with 
squamous  epithelium,  and  contains  in  its  substance  numerous 
closed  follicles,  particularly  at  the  level  of  the  lateral  parts 
behind  the  posterior  pillars.  It  possesses  also  numerous 
groups  of  glands. 

Vessels  and  Nerves. — ^The  arteries  are  derived  from 
the  pharyngeal,  a  branch  of  the  external  carotid,  and  from 
the  pterygo-palatine. 

The  veins,  forming  a  superficial  and  deep  plexus,  flow  into 
the  internal  jugular. 

The   higher  set  of  lymphatics    enters  a   gland  situate   at 


lo  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

the  level  of  the  highest  part  of  the  superior  constrictor 
(Sappey),  while  the  lower  enters  a  group  of  glands  situate 
in  front  of  the  common  carotid,  close  to  its  bifurcation. 

The  nerves  issue  from  the  pharyngeal  plexus.  According  to 
Testut,  physiological  investigation  informs  us  that  the  sensi- 
bility of  the  mucous  membrane  is  derived  from  the  pneumo- 
gastric,  while  the  vascular  and  secretory  phenomena  are 
under  the  influence  of  the  superior  cervical  ganglion.  The 
muscles  are  innervated  by  the  glosso-pharyngeal  and  the 
spinal  accessory. 

The  Examination  of  the  Pharynx. 

Owing,  it  may  be,  to  the  tongue,  to  the  reflexes,  or  to 
faultiness  in  technique,  the  examination  of  the  throat  is  not 
so  easy  as  might  at  first  appear.  The  practice  of  asking  the 
patient  to  put  out  his  tongue  ought  to  be  condemned,  as  it 
gives  rise  to  many  errors. 

To  examine  thoroughly  the  pharynx  it  is  necessary — 

1.  To  ask  the  patient  to  open  his  mouth  widely,  and,  by 
fully  retracting  the  lips,  to  show  the  teeth. 

2.  To  keep  the  tongue  in  the  mouth  behind  the  dental  arch,  and 
thus  enable  the  tongue-depressor  to  be  placed  with  firm  but 
gentle  pressure  on  the  anterior  third  of  that  organ.  On  the 
patient  sounding  the  vowel  'ah,'  the  whole  cavity  may  be 
perfectly  examined  without  causing  any  reflex  nausea.  This 
enables  one  to  see  clearly  the  soft  palate,  the  uvula,  the 
pillars,  the  tonsils,  the  buccal  pharynx,  and,  while  the  soft 
palate  is  raised,  the  lower  part  of  the  naso-pharynx. 

The  apex  of  the  epiglottis  is  often  seen  in  docile  patients,, 
and  in  the  case  of  children  it  is  almost  always  possible  to  see 
the  operculum  during  the  act  of  swallowing. 

If  the  tongue  is  refractory  and  arching  takes  place,  all  that 
is  usually  necessary  is  to  reassure  the  patient,  so  that  he  may 
allow  successive  small  taps  to  be  made  over  its  dorsal  surface, 
and  gradually  this  tendency  will  be  overcome,  and  the  organ 
will  lie  on  the  floor  of  the  mouth. 

Breathing  should  be  easy  in  order  to  enable  one  correctly 


THE  AXATOMY  OF  THE  PHARYNGEAL  CAVITY         ii 

to  judge  of  the  appearance  of  this  region,  as  very  often 
at  the  first  glance  the  mucous  membrane  is  seen  to  be 
red  from  venous  stasis,  caused  by  the  difficulty  of  opening 
the  mouth,  and  the  involuntar}-  contractions  made  by  the 
patient  at  the  beginning  of  the  examination.  With  beginners 
this  is  a  frequent  source  of  error.  The  size  of  the  tonsils 
should  not  be  estimated  during  the  act  of  straining,  especiall}- 


Fig,  3 


-Position-  of  the  Tongue  and  of  the  Tongue-Depressor  during 
Examination  of  the  Pharyngeal  Cavity. 


I,  Soft  palate  and  origin  of  the  anterior  pillar  ;   2.  posterior  pillar  ;  3,  left 
tonsil  ;  4,  wall  of  the  buccal  pharynx. 

in  children,  as  the  tonsils  may  project  inwards  from  the 
pillars,  while  in  quiet  respiration  they  are  nearly  normal. 

With  certain  people,  or  with  professional  singers  accustomed 
to  look  at  their  own  pharynx,  there  is  no  need  to  use  a 
tongue-depressor,  as  they  have  got  into  the  habit  of  keeping 
the  tongue  well  down  on  the  floor  of  the  mouth. 

For  examinations  of  the  laryngo-pharynx  or  the  base  of 
the  tongue  the  laryngoscopic  mirror  should  alwa3-s  be  used. 


CHAPTER  II 

PATHOLOGY  OF  THE  PHARYNX 

Erythematous  Angina. 

A  SUPERFICIAL  catarrhal  inflammation  of  the  pharyngeal 
mucous  membrane. 

Symptoms. — This  condition  is  speciall}"  characterized  by 
general  malaise  rather  than  by  fever,  and  by  severe  pain, 
particularly  on  deglutition,  the  pain  being  more  marked  in 
the  case  of  semi-solids. 

On  examination,  the  soft  palate,  and  especially  the  base 
of  the  anterior  pillar,  show  a  blotchy  redness,  more  or  less 
vivid,  and  often  there  are  found  scattered  over  the  surface  of 
the  mucous  membrane,  particularly  at  the  angle  formed 
by  the  tongue  and  the  anterior  pillar,  whitish  erosions, 
irregular  in  form. 

These  very  superficial  erosions  are  sometimes  discrete,  and 
only  occupy  a  small  area  of  the  pharynx,  but  they  may  be 
diffused  over  the  base  of  the  tongue.  They  may  even  reach 
the  lingual  surface  of  the  epiglottis  or  its  edge,  making 
deglutition  very  painful. 

Aphthous  angina  shows  a  great  analogy  to  this  form,  but 
has  usually  mucous  patches  over  the  cheeks,  lips,  edges  of 
the  tongue,  etc.,  and  the  erosions  are  more  regular,  deeper 
and  more  discrete— two  or  three  at  the  most.  This  may 
sometimes  be  associated  with  a  variety  of  urticaria  of  the 
pharynx  and  larynx. 

Treatment  consists  in  the  use  of  emollient  gargles,  alkalies, 
chlorate  of  potash,  borax,  etc.,  painting  of  the  erosions  with 
a  solution  of  zinc  chloride  (2  per  cent.),  or,  still  better,  with 
a  solution  of  nitrate  of  silver  (2  per  cent.j.  The  use  of 
alkalies  internally,  with  milk,  Vichy  water,  eggs,  is  specially 


PATHOLOGY  OF  THE  PHARYNX  13 

useful  in  relieving  this  complaint.  The  disease  is  apt  to 
recur  from  trivial  causes,  such  as  smoking,  the  ingestion  of 
spiced  foods,  shell-fish,  and,  above  all,  strawberries. 

It  appears  most  commonly  in  spring  and  autumn,  and  is 
more  frequent  with  men  than  with  women.  It  is  quite  often 
seen  in  3'oung  people,  while  they  are  cutting  their  wisdom 
teeth.  In  its  later  stages  painting  with  iodine  or  astringent 
srarsfles  is  recommended. 


Erythema  Polymorphia. 

This  occurs  most  frequently  during  spring  and  autumn, 
and  is  encouraged  in  individuals  predisposed  to  it  b}'  eating 
certain  fruits,  such  as  strawberries.  It  is  characterized  by 
the  appearance,  of  a  recurring  erythema,  with  little  superficial 
erosions,  covered  with  a  thin  greyish  pellicle,  which  can  be 
easily  removed  with  a  swab.  These  are  situate  over  the 
pharynx  and  soft  palate,  but  more  especially  over  the  tonsils 
or  the  anterior  pillars. 

It  is  generally  of  short  duration — from  twenty-four  to 
forty-eight  hours — and  it  resembles  a  superficial  burn.  On 
removing  the  pellicle  a  red  ulcer  of  round  or  crescent  shape, 
outlined  by  a  greyish  border,  is  observed. 

These  eruptions  are  found  usually  on  the  mucous  surface 
of  the  cheeks,  often  on  the  lips,  and  even  on  the  back  and 
sides  of  the  tongue.  They  are  very  rarely  found  on  the 
pharyngeal  wall. 

The  characteristic  feature  of  this  erythema  is  the  rapidity 
of  its  evolution  and  the  ephemeral  pemphigal  elevation  at  the 
beginning,  which  is  difficult  to  diagnose,  as  the  pellicle  of 
macerated  epithelium  comes  away  on  the  least  movement  of 
the  tongue  or  even  in  deglutition.  After  healing  up  it  is  very 
apt  to  return  in  spite  of  all  treatment. 

This  lesion  may,  at  the  first  glance,  be  mistaken  for  a 
mucous  patch,  but  it  has  neither  the  opalescent  colour  nor 
the  red  inflammatory  border  so  characteristic  of  the  syphilitic 
plaque.  Besides,  the  shape  is  different,  the  polymorphic 
erythema    resembling    leaf -like    indentations    or    festoons, 


14  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

covered  with  a  membranous  pellicle,  which  is  easily  removed, 
and  leaving  a  superficial  excoriation.  In  the  middle  of  the 
patch  the  mucous  membrane  may  be  perfectly  healthy. 

Treatment  consists  principally  in  the  use  of  alkalies, 
borated  gargles,  the  painting  of  the  ulcerated  parts  with 
a  2  per  cent,  solution  of  zinc  chloride,  after  applying 
cocaine,  or  the  use  of  the  nitrate  of  silver  pencil  or  a  20  per 
cent,  solution. 


Pemphigus  of  the  Pharynx. 

This  may  be  acute  or  chronic. 

(a)  The  acute  form  is  by  far  the  less  known.  It  is  difficult 
to  diagnose,  as  there  are  no  accompanying  cutaneous  lesions. 

Etiology. — Its  causes  are  very  badly  defined.  It  is  seen  at 
all  ages,  and  it  is  not  influenced  by  the  seasons. 

Symptoms.  —  Pemphigus  usually  has  a  sharp  onset,  the 
patient  suddenly  complaining  of  acute  pain,  like  that  of  a 
burn,  in  the  pharynx.  This  generally  takes  place  in  the 
morning  on  waking,  or  even  when  taking  food. 

If  the  throat  is  examined  one  or  more  blisters  are  seen  over 
the  palate,  especially  around  the  uvula.  These  blisters  vary 
much  in  size,  from  a  lentil  to  that  of  a  large  almond,  and  are 
of  oval  or  rounded  outline.  The  author  has  seen  one  large 
enough  to  cover  the  greater  part  of  the  soft  palate.  The 
fluid  contained  in  these  blisters,  which  may  be  serous  or 
bloody  (haemorrhagic  form),  causes  the  mucous  membrane  to 
project.  The  projection  is  surrounded  by  a  red  border,  with- 
out any  peripheral  infiltration. 

Pemphigus  is  occasionally  met  with  on  the  epiglottis  and 
over  the  arytenoid  cartilages. 

At  the  second  stage,  when  the  fluid  escapes,  a  wrinkled, 
opalescent  membrane  is  left,  resembling  a  broken  blister. 
Soon  after  it  has  the  appearance  of  a  yellowish  or  greyish- 
white  fibrinous  patch  implanted  on  the  mucous  membrane. 
This  membrane  is  surrounded  by  a  reddish  border,  which  is 
never  infiltrated. 

Subjectively  the  patient  complains  of  a  burning  sensation 


PATHOLOGY  OF  THE  PHARYNX  15 

in  the  throat,  especially  while  swallowing  warm  or  salted 
liquids.  Beyond  this  there  are  no  constitutional  disturb- 
ances, whereas  in  general  pemphigus  the  onset  is  ushered 
in  by  severe  headache,  shivering,  and  rise  of  temperature. 

The  course  of  this  affection  is  rapid,  and  one  attack  gives 
no  immunity,  as  the  author  has  seen  frequent  relapses. 

The  prognosis  is  most  favourable. 

Diagnosis.  —  This  is  to  be  distinguished  from  simple 
erythematous  angina,  the  angina  of  secondary  syphilis,  and 
that  caused  by  the  use  of  certain  drugs. 

The  simple  erythematous  angina  is  usually  accompanied 
by  feverish  symptoms,  dry,  painful  throat,  so  that  degluti- 
tion is  nearly  impossible  ;  besides,  the  symptoms  are  quite 
different  from  those  of  acute  pemphigus. 

In  syphilitic  angina  there  is  some  analogy,  but  the 
syphilitic  lesion  is  usually  situate  on  the  pillars,  the  tonsils, 
the  inner  surface  of  the  lips,  but  very  rarely  on  the  middle 
part  of  the  palate.  The  patch  has  a  carmine-coloured 
border,  and  erythema  is  present,  and  tumefaction  of  the 
pharynx,  which  ought  to  prevent  confusion  in  the  diagnosis. 

The  use  of  certain  drugs,  such  as  iodide  of  potassium 
and  antipyrin,  has  been  known  to  cause  phlyctenular 
erythematous  stomatitis,  which  might  be  mistaken  for 
pemphigus  proper. 

Treatment. — This  is  very  simple,  as  the  tendency  of  the 
disease  is  to  disappear  of  itself.  During  the  first  few  days  a 
semiliquid  diet  is  recommended,  preferably  alkalinized,  such 
as  milk,  eggs,  Vichy  water  ;  later  on,  cold  emollient  gargles, 
heat  being  disagreeable  to  the  patient.  In  fine,  as  much 
rest  as  possible  should  be  given  to  the  affected  parts. 

If  the  bulla  is  entire  at  the  time  of  examination  it  may  be 
incised. 

[h)  The  chronic  form. 

Etiology. — Chronic  pemphigus  appears  to  be  a  disease  of 
adults,  even  at  an  advanced  age,  and  is  invariably  found  in 
feeble  or  cachectic  individuals.  It  appears  to  be  specially 
frequent  in  Germany  and  Austria. 

This    form    is    usually    subsequent    to   general    affections, 


1 6  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

spreading  from  the  skin  to  the  buccal  mucous  membrane, 
from  thence  to  the  pharynx,  and  even  to  the  nose  and 
larynx.  The  conjunctivae  are  affected.  The  course  of 
extension  is  very  irregular.  The  skin  lesions  may  precede 
those  of  the  mucous  membrane  by  six  weeks  to  three  years. 
Some  believe  this  is  a  primary  lesion,  and  that  the  mucous 
membrane  is  affected  two,  three,  or  even  four  months  before 
the  skin.  The  pemphigus  may  assume  the  foliaceous  or 
bullous  form. 

Finally,  cases  are  observed  where  the  pemphigus  remains 
localized  in  the  mucous  membrane  without  reaching  the 
skin. 

Symptoms. — As  a  rule,  chronic  pemphigus  is  very  insidious 
in  its  onset,  the  patient  complaining  of  abnormal  dryness 
in  his  throat,  or  of  slight  pain  during  the  act  of  deglutition 
of  hot  or  spiced  foods.  Epistaxis  and  the  separation 
of  false  membrane  occur  where  the  nose  is  affected.  This 
condition  may  go  on  for  months  or  years  without  the  patient 
knowing  that  he  is  ill,  until  the  disease  has  made  such 
progress  that  he  seeks  advice. 

It  is  rare  to  find  the  bullous  stage,  as  this  is  so  ephemeral. 
When  present,  the  bullae  exhibit  the  same  translucent  or 
blackish  appearance  as  in  acute  pemphigus.  When  the  bulla 
has  broken,  there  remains  in  its  place  a  fibrinous  exudation, 
yellowish-white  in  colour,  wrinkled,  and  of  fairly  regular 
form.  This  membrane  is  generally  attached  to  the  mucous 
membrane  in  all  its  extent,  but  one  of  the  edges  may  be  seen 
to  be  raised,  and  through  the  movement  of  the  tongue  and 
deglutition  it  is  detached,  leaving  the  red  mucosa  sometimes 
granular  or  blood-stained.  In  four  to  ten  days  at  most  it 
heals  up,  without  leaving  a  cicatrix. 

On  the  conjunctivae  the  fibrinous  exudation  is  followed  by 
ulceration  and  by  adhesions  between  its  palpebral  and  ocular 
layers,  and  the  cul-de-sac  tends  to  disappear.  The  cornea 
ulcerates,  and  becoming  vascular  and  sclerosed,  forms  a  true 
pannus. 

The  sight  becomes  feeble,  and  finally  is  lost,  either 
from  corneal  opacity  or  from  the  gradual  compression  and 


PATHOLOGY  OF  THE  PHARYNX  i? 

atrophy  of  the  optic  bulb.  In  graver  forms  the  successive 
bullae  are  very  close  to  each  other,  forming  thick  exudates, 
covering  over  the  mucous  membrane  of  the  soft  palate, 
tongue,  gums,  nose,  pharynx,  and  even  the  arytenoids,  vocal 
cords,  and  trachea. 

The  healing  of  these  tissues  is  slow  ;  ulcerations  form, 
which  leave  synechise  or  cicatrices  behind.  The  functional 
symptoms  depend  on  the  seat  and  the  nature  of  the  lesions. 
If  they  are  large  or  deep,  discomfort  and  even  acute  pain  are 
felt,  especially  during  deglutition.  Even  respiration  may  be 
affected,Towing  to  the  nares  becoming  blocked  with  thick 
crusts. 

Fever  is  absent,  but  in  grave  and  rapid  forms  each  eruption 
may  be  ushered  in  with  headache  or  even  shivering. 

As  a  general  rule,  the  lymphatic  system  is  unaffected. 

The  duration  of  the  disease  is  extremely  variable  ;  some- 
times the  course  is  very  slow. 

In  the  still  graver  forms  early  ulceration  supervenes, 
rendering  the  taking  of  food  difficult. 

The  prognosis  depends  on  the  mode  of  development,  its 
form,  and  especially  on  the  susceptibility  of  the  individual. 
Occasionally  the  affection  remains  stationary  for  several 
years,  or  it  may  occur  for  some  months,  with  periods  of  very 
marked  improvement  ;  but  it  is  rare  not  to  have  relapses, 
and  a  cure  has  not  been  recorded. 

As  a  rule,  bacteriology  does  not  help  us  much,  having 
usually  a  negative  result. 

Kapozzi  found  on  post-mortem  examination  sclerosis  of 
the  lateral  columns  of  the  cord.  Atrophic  functional  disease 
of  the  nervous  system  might  explain  the  appearance,  and, 
above  all,  its  essentially  chronic  relapsing  nature. 

The  diagnosis  of  pemphigus  isolated  on  the  mucous 
membrane  is  very  difficult,  especially  if  the  case  is  not  seen 
during  the  bullous  condition.  At  first  it  might  be  confused 
with  an  erythematous  stomatitis  or  even  secondary  syphilis. 
The  former,  however,  is  temporary  and  extremely  painful, 
while  the  latter  is  usually  accompanied  by  other  bullae,  which 
point  to  a  diagnosis. 

2 


I  s  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

Treatment. — General  treatment  is  of  no  avail.  Mercury 
and  iodide  of  potassium  only  aggravate  the  condition.  Large 
doses  of  Fowler's  solution  (Hutchinson)  in  20  to  30  drop 
doses  appear  to  benefit  its  course  slightly. 

Local  treatment  by  means  of  washes  and  gargles,  emollient 
or  alkaline,  and  attention  to  the  hygiene  of  the  mouth, 
subdue  to  some  extent  the  pain  and  check  its  course.  If 
the  pain  is  very  sharp,  insufflations  of  orthoform,  pure  or 
mixed  with  borate  of  soda,  are  useful,  as  well  as  the  local 
application  of  a  solution  of  cocaine  and  glycerine. 

The  diet  should  be  nourishing,  and  neither  spiced  nor  hot. 

Acute  Catarrhal  Angina— Tonsillar  Congestion. 

This  is  an  acute  inflammation,  circumscribed  or  diffused, 
of  the  pharynx,  characterized  by  redness  and  slight  swelling. 

Etiology. — Acute  pharyngitis  occurs  at  certain  seasons, 
especially  during  summer.  It  appears  to  be  common  in 
rheumatic  subjects,  where  it  assumes  the  character  of  ton- 
sillar congestion.  Although  it  is  not  easy  to  establish  the 
relation  of  cause  and  effect  between  rheumatism  or  gout 
and  this  particular  form  of  affection,  yet  it  is  none  the  less 
true  that  there  has  been  observed  in  some  individuals  the 
coexistence  of  a  fleeting  pain  in  the  joints,  acute  mus- 
cular rheumatism  or  catarrhal  angina.  In  some  cases  they 
alternate.  Damp  and  chill  are  the  usual  causes  of  this  affec- 
tion, which  exhibits  frequent  relapses. 

The  onset  is  usually  acute,  accompanied  by  malaise  and 
slight  gastro-intestinal  disturbance.  This  is  followed  rapidly 
by  painful  sensations  in  the  throat,  increased  by  movement 
of  the  tongue  or  palate.  Though  less  acute  than  in  the 
exudative  forms,  the  pain  may  be  so  intense  as  to  hinder 
deglutition.  It  may  be  felt  over  all  the  phar}-nx  or  on  one 
side,  according  as  the  lesion  is  general  or  local.  It  is  usual 
for  the  pain,  especially  in  rheumatic  forms,  to  be  worse  in 
the  evening,  or  after  prolonged  use  of  the  voice. 

On  examination  in  the  localized  form,  redness  over  one  of 
the  pillars  and  tonsil  is  seen. 


PATHOLOGY  OF  THE  PHARYNX  19 

In  the  diffuse  variety  the  soft  palate,  the  uvula,  and  the 
anterior  pillars  are  involved  ;  the  uvula  may  be  œdematous. 
In  this  affection  there  is  no  exudation  or  glandular  en- 
largement. 

The  localized  form  is  most  usually  seen  in  rheumatic 
patients.  In  mild  cases  recovery  may  take  place  in  forty- 
eight  hours,  but  it  may  be  prolonged  for  five  or  six  days 
at  most. 

The  manner  of  onset,  progress,  and  the  absence  of  pul- 
taceous  tonsillar  exudation  enable  one  to  make  a  diagnosis. 
Early  erythematous  syphilis  of  the  pharynx  may  be  mistaken 
for  this  affection,  but  generally  in  the  syphilitic  lesion  in- 
flammatory symptoms  are  much  less  acute  and  the  pain  is 
less  severe  ;  besides,  there  is  no  infiltration  of  the  parts. 
The  progress  of  the  disease  soon  confirms  diagnosis,  if  there 
should  have  been  any  doubt. 

The  angina  of  scarlet  fever  covers  not  only  the  pharynx 
but  the  entire  buccal  cavity,  particularly  the  inner  surface  of 
the  cheeks.  The  purplish-red  colour  is  almost  characteristic 
of  the  affection.  There  is  often  an  exudation  on  the  tonsillar 
crypts,  and  in  every  case  the  temperature,  the  violence  of 
the  general  infection,  and  the  existence  of  the  cutaneous 
eruption  point  to  the  diagnosis. 

Pharyngeal  urticaria  has  a  rapid  course,  alternating  usua 
with  gastro-intestinal  disorder  or  with  similar  skin  symptoms, 
and  is  especially  developed  after  the  ingestion    of  certain 
foods     (fish,     Crustacea,     shell -fish,     mussels,     strawberries, 
cherries,  etc.),  or  from  over-indulgence. 

Treatment. — Alkaline  gargles,  warm  inhalations,  intestinal 
antiseptics,  as  salol,  sulphate  of  quinine,  benzoate  or 
salicylate  of  soda,  with  milk  diet,  are  indicated. 

Acute  Tonsillitis. 

A  diffuse  inflammation  of  the  pharynx,  characterized  by 
redness  and  swelling,  and  by  a  whitish  deposit  over  the 
tonsil. 

Etiology. — This  affection  is  much  more  common  in  children 

2 — 2 


20  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

and  during  adolescence,  and  is  rare  in  old  people  on  account 
of  the  loss  of  lymphatic  tissue. 

The  shape  of  certain  tonsils  and  the  existence  of  previous 
attacks  render  the  patient  liable  to  a  recurrence  of  the 
disease.  The  most  common  cause  is  a  chill.  It  may  follow 
certain  traumatisms,  as  cauterization  of  the  nasal  mucosa 
or  of  the  lingual  tonsil,  and  puncture  of  the  maxillary  sinus. 

Climatic  changes  play  an  important  rôle,  and  nasal  ob- 
struction, adenoids,  and  emp3^ema  of  the  accessory  sinuses 
all  predispose  to  this  lesion. 

Symptoms. — The  disease  is  usually  announced  by  shivering, 
severe  headache,  malaise,  and  fever.  This  is  slight,  or  if  the 
tonsillar  inflammation  be  severe  the  temperature  may  reach 
from  39°  C.  to  40°  C.  It  soon  falls,  but  rises  again,  and  in  a 
more  violent  form,  after  twenty-four  hours.  Very  soon  the 
patient  complains  of  uneasiness  in  the  throat,  on  one  side  or 
on  both,  according  to  whether  the  inflammation  is  localized 
or  diffused.  This  passes  into  severe  pain,  often  extending 
to  the  ears,  and  is  increased  on  movement  of  the  tongue, 
deglutition,  etc.  In  children  movements  of  the  head  and 
neck  are  difficult  ;  the  submaxillary  or  the  cervical  glands 
are  painful  and  inflamed,  and  even  produce  a  torticollis. 
The  voice  becomes  nasal,  thick,  and  tonsillar,  the  tongue 
foul,  the  appetite  moderate,  with  persistence  of  malaise  and 
depression. 

On  examination  during  the  first  stage  a  simple  diffuse 
redness  is  seen  occupying  the  site  of  the  tonsils,  and  in  many 
cases  the  uvula.  As  early  as  the  second  day  a  whitish  coat- 
ing appears  on  the  swollen  and  enlarged  tonsillar  crypts. 
This  does  not  cover  the  gland,  but  is  more  or  less  discrete, 
a  dirty  greyish  pultaceous  exudation  being  studded  here  and 
there  in  patches,  between  which  the  red  and  inflamed  mucous 
membrane  can  be  seen. 

If  inflammation  has  spread  to  the  lateral  walls  of  the 
pillars,  or  even  to  the  orifice  of  the  tubes,  earache,  deafness, 
and  tinnitus  may  be  complained  of. 

About  the  fourth  or  fifth  day  the  symptoms  abate,  degluti- 
tion becoming  easier. 


PATHOLOGY  OF  THE  PHARYNX  21 

If  both  sides  have  been  affected,  the  patient  soon  recovers  ; 
but,  as  it  often  happens,  the  affection  may  have  been  unilateral, 
and  the  other  side  is  now  attacked.  In  these  cases  the 
febrile  symptoms  are  slightly  less  intense,  but  they  may — 
especially  in  children — become  very  violent. 

As  a  rule  a  cure  is  obtained,  but,  in  young  people  chiefly, 
hypertrophy  may  take  place  and  the  tonsils  become  the  seat 
of  chronic  inflammation. 

Complications. — The  usual  complications  are  abscess  in 
the  tonsil,  chronic  or  suppurative  adenitis,  slight  arthritis, 
nephritis,  endocarditis,  perichondritis,  and  otitis.  Palatal 
paralysis  is  not  very  rare  after  a  severe  though  simple  angina. 
Perhaps  this  may  be  connected  with  diphtheria  or  other 
infectious  anginse  without  the  production  of  false  membrane, 
and  yet  in  the  bacteriological  examination  of  several 
analogous  cases  the  author  has  only  found  streptococci 
and  diplococci. 

Diagnosis  is  nearly  always  easy.  In  the  angina  of  scarlet 
fever  the  tonsils  are  generally  bilaterally  affect(id  from  the 
first,  the  pharynx  and  the  soft  palate  being  bright  red,  smooth, 
and  without  œdematous  infiltration. 

The  tonsils  are  often  covered  by  a  pultaceous  white  deposit, 
which  is  not  removed  by  brushing  over  with  a  solution  of 
chloride  of  zinc.  The  duration  of  the  angina  is  longer,  and 
the  mouth,  tongue,  and  lips  preserve  for  several  days  the 
smooth,  dry,  characteristic  carmine  tint.  The  progress  of 
the  fever  and  the  duration  of  the  disease  scarcely  permit  of 
a  mistake  in  diagnosis,  not  to  speak  of  the  cutaneous  eruption, 
which  is  found  nearly  always  on  certain  parts  of  the  body — 
hands,  feet,  arms,  and  the  internal  surface  of  the  thighs. 

Herpetic  angina  and  folliculitis  may  be  confused,  and  this 
the  author  believes  often  occurs  in  practice. 

Treatment. — The  administration  of  tincture  of  aconite  or  of 
quinine,  with  a  saline  purge,  is  very  satisfactory. 

Locally  the  author  prescribes,  where  there  is  much  pain, 
inhalations  three  or  four  times  a  day  for  five  to  ten  minutes. 
Emollient  gargles,  especially  alkaline,  are  also  recom- 
mended. 


DISEASES  OE  THE  PHARYNX  AXD  LARYNX 


Biborate  of  soda  \ 
Benzoate  of  sodaj 

aa  4  grammes 

J  gr.  60 
1  gr.  60 

Spirit    of  peppermint  ('  alcool 

de  menthe  ') 

5 

n]_lxxx 

Pure  glycerine 

Decoction  of  barley  and  coca- 

50 

ôxi 

leaves     ... 

450 

5xvi 

To  this  gargle  add  two-thirds  of  hot  marsh-mallow  water, 
and  use  it  to  bathe  the  throat  every  hour  or  two,  according 
to  the  severity  of  the  inflammation. 

The  diet  should  be  simple,  eggs  and  milk  food  for  the  first 
three  or  four  da}-^. 

If  inflammation  is  observed  at  a  very  early  stage,  or  even 
later,  the  part  might  be  painted  with  a  solution  of  zinc 
chloride,  i  in  20  or  i  in  ^,0. 


The  author  uses  the  following 


R    Chloride  of  zinc   ... 
Hydrochloric  acid 
Hydrochloride  of  cocaine 


I  gramme 
h  drop 


gr-ao 


gr.  3  to  6 


Glycerine 
Distilled  water 


10  to  20  centi- 
grammes 
5  grammes  ~ii 

20  to  30  grammes    ox  to  xv 


This    should    onh-   be   applied    once,   and   not    later    than 
forty-eight  hours  after  the  onset. 
Another  good  formula  is  : 


R  Biborate  of  soda  ... 

H3'drochloride  of  cocaine   .., 

Pure  glycerine 


4  grammes 
15  to  20  centi- 
grammes 
15  grammes 


gr.6o 

gr.  2  to  3 

^iiiss 


This  is  preferable  to  employing  syrupy  materials,  as  it  is 
aseptic  as  well  as  sweet  to  the  taste. 

When  the  submaxillary  or  cervical  glands  are  very  painful, 
and  if  any  torticollis  be  present  (children's  angina),  the  appli- 
cation of  tincture  of  iodine,  ^\•arm  poultices,  or  wadding  gives 
excellent  results. 


PATHOLOGY  OF  THE  PHARYNX  23 

Herpetic  Angina. 

An  acute  inflammation  of  the  pharynx  characterized  by 
a  growth  of  herpetic  vesicles  scattered  over  its  surface. 

Etiology. — This  is  difficult  to  determine. 

Predisposition  plays  an  important  part,  one  attack  pre- 
disposing to  others.  The  disease  is  more  frequent  in 
adolescence  and  in  adult  age. 


Fig.  4. — Herpetic  Vesicles  on  the  Pharyngeal  Wall. 

Symptoms. — The  onset  is  usually  sudden,  with  shivering, 
lassitude,  and  anorexia. 

The  temperature  rises  rapidly  to  39*5°  C.  to  40°  C,  or  over. 
After  twenty-four  to  thirty-six  hours'  time,  deglutition  is 
considerably  interfered  with,  so  that  the  patient  can  neither 
swallow  solid  nor  liquid  food. 

On  examination  of  the  pharynx,  congestion  and  tumefac- 
tion can  be  observed  over  the  pillars,  soft  palate,  and 
phar3'ngeal  wall.  A  crop  of  vesicles  scattered  in  groups 
then  appears.     They  may  also  be  seen  on  the  base  of  the 


24  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

tongue  and  epiglottis.  If  they  occur  on  the  Hps  they  rupture 
early,  and  form  a  characteristic  brownish-yellowish  crust. 
The  si^e  of  each  vesicle  is  about  that  of  a  hemp-seed.  It  is 
at  first  filled  with  a  transparent,  slightly  turbid  liquid.  In 
a  few  hours  the  vesicle  ruptures,  leaving  a  round  greyish 
surface,  surrounded  by  an  inflammatory  border. 

The  eruption  takes  place  either  all  at  once  or  in  successive 
groups,  accompanied  by  fresh  feverish  symptoms.  Glandular 
involvement  is  generally  little  marked.  The  principal  symptom 
is  intense  pain  on  deglutition,  which  is  more  severe  in  propor- 
tion to  the  diffusion  of  the  eruption  as  well  as  to  its  position 
—e.g.,  the  epiglottis  or  lingual  tonsil. 

This  disease  usually  lasts  from  four  to  six  days.  Com- 
plications are  rare  ;  the  inoculation  of  diphtheria  on  the 
ulceration  is  the  only  grave  one. 

The  prognosis  is  good. 

In  some  cases  there  is  difficulty  in  making  a  diagnosis. 
At  the  onset  it  may  be  confused  with  simple  tonsillitis, 
erysipelas,  or  scarlatina,  till  the  appearance  of  the  vesicles. 
The  only  important  differential  diagnosis  is  between  it  and 
diphtheritic  angina,  when  the  false  membrane  is  present.  The 
following  points  should  settle  the  diagnosis — viz.,  the  sudden 
onset,  the  very  high  temperature,  the  existence  of  herpetic 
vesicles  on  the  soft  palate,  lips,  pharynx,  and  base  of  tongue. 
The  functional  symptoms  are  also  generally  more  marked  in 
herpetic  angina  than  in  diphtheria.  Dysphagia,  which  is 
very  intense  in  the  former,  in  less  marked  in  pseudo- 
membranous angina,  and  glandular  involvement  is  more 
pronounced  in  the  latter  than  in  herpes. 

On  the  other  hand,  if  diphtheria  were  grafted  on  a 
herpetic  angina,  the  symptoms  would  be  graver  and  the 
fever  more  persistent.  If  in  doubt,  it  should  be  treated  as 
a  case  of  diphtheria,  and  still  more  so  if  bacteriological 
examination  shows  the  presence  of  the  Loeffler  bacillus. 

Herpes  of  the  pharynx  (the  '  zona  pharyngé  '  of  Herzog, 
Lermoyez,  and  others)  is  distinguished  from  ordinary 
herpetic  angina  by  the  following  points  :  less  general  con- 
stitutional   disturbance,    pains    more    neuralgic,    and    with 


PATHOLOGY  OF  THE  PHARYNX 


25 


occasionally  a  burning  sensation.  According  to  Larmoyez, 
the  pain  diminishes,  when  the  vesicles  appear. 

The  distribution  is  generally  unilateral,  and  in  the  region 
supplied  by  the  superior  maxillary  nerve.  Its  duration  is 
longer  than  in  herpetic  angina,  and  may  extend  from  fifteen 
to  twenty  days.  Lastly,  one  attack  usually  protects  the 
individual  from  others. 

Treatment. — An  alkaline  purgative,  or  quinine,  with  or 
without  antipyrin,  are  very  efficient  remedies. 


Fig.  5. — Acute  Lacunar  Ulceration,  Situate  at  the  Inferior  Part  of 
THE  Right  Tonsil,  which  is  Hypertrophied  Anteriorly. 

Locally,  alkaline  gargles,  with  borax,  are  indicated,  or  the 
following  paint  : 

R  Solution  of  carbolate  of  soda     i  gramme  Il\xv 

Resorcin  ...  ...     5  centigrammes        gr.  7^- 

Glycerine  (neutral)  ...     50  grammes  3xi 

Paint  the  throat  once  daily.     General  tonic  treatment  is 
also  recommended. 


Acute  Ulcerative  Lacunar  Tonsillitis. 

The  author  believes  he  is  the  first  to  describe  under  this 
name  a  special  form  of  tonsillitis,  characterized  by  an 
extensive  crateriform  ulceration. 


26 


DISEASES  OF  THE  PHARYNX  AND  LARYNX 


Etiology. — This  condition  is  seen  more  frequently  in  spring 
and  autumn,  and  may  occur  as  an  epidemic.  It  is  rarer  in 
children  and  in  adults  above  forty,  and  is  chiefly  observed  in 
those  who  are  debilitated,  or  have  received  a  chill. 

There  is  no  doubt  that  the  lacunar  disposition  of  the 
tonsils,  the  depth  of  the  crypts,  their  comparatively  small 
apertures,  and  the  existence  of  caseous  tonsillitis,  all  pre- 
dispose to  this  affection.  The  ulcerative  process  appears  to 
be  of  microbic  origin,  yet  the  bacilli  discovered,  whether  by 
direct    growth    or   by  cultivation,   are   varied — streptococci. 


Fig.  6. — Acute  Ulcerative  Lacunar  Tonsillitis. 

In  this  case  two  ulcers  appear  on  the  left  tonsil — one  superiorly  (shown  in 
profile),  the  other  inferiorly  (shown  full-face). 


pneumococci,    sometimes     staphylococci,    fusiform     bacilli, 
spirilli,  and  a  long,  thin  bacillus  of  uncertain  nature. 

Thus,  although  we  admit  the  microbic  nature  of  the 
ulceration,  we  must  seek  the  cause  of  it  in  the  acute  inflam- 
mation of  the  crypts  themselves,  whose  products  of  desquama- 
tion cannot  get  free,  either  by  the  blocking  of  the  orifice  or 
the  superdilatation  of  one  or  several  lacunae.  It  is  from  the 
rupture  of  those  crypts  that  the  anfractuous  cavity,  filled  with 
epidermal  detritus,   is  produced,   as  well    as   the   deform.ed 


PATHOLOGY  OF   THE  PHARYNX 


27 


follicles  observed  in  those  cases.     The  loss  of  substance  is 
similarly  explained. 

Symptoms. — The  onset  of  the  disease,  sometimes  febrile,  is, 
for  the  most  part,  insidious,  and  may  pass  unobserved,  till 
the  patient  begins  to  experience  a  slight  difficulty  or  pain  in 
deglutition.  This  pain,  localized  at  the  level  of  the  tonsil, 
shoots  up  to  the  ear  of  the  diseased  side.  The  buccal  lesion 
consists  in  an  ulceration  of  greyish  appearance,  covered  with 
caseous  material,  readily  detachable  with  the  cotton  mop, 
leaving  a  blood-stained,  reddened  surface. 


Fig.  7. — Ulcerative  Lacunar  Tonsillitis  of  the^Right 
Tonsil. 

The  edges  are  slightly  red,  clean,  punched  out,  and  bleed 
easily.  They  are  not  infiltrated.  The  lesion  is  very  like 
that  produced  by  the  thermo-cautery,  when  the  slough  is 
beginning  to  separate.  The  tonsil  is  not  enlarged,  and  the 
pillars  are  not  involved.  The  lymphatic  system  is  not 
generally  affected,  and  the  buccal  mucosa  remains  intact. 

Pathologically,  we  can  consider  it  as  having  a  pre-ulcerous 
and  an  ulcerous  stage.  In  the  former  we  find  an  encysted 
lacunar  tonsillitis,  either  latent  or  in  process  of  ulceration. 
When  latent  it  can  readily  pass  unnoticed.  Its  contents  are 
composed  of  a  hyaline  material,  which  does  not  readily  stain 


28  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

with  epithelial  reagents,  and  no  nuclei  are  seen.  They  appear 
to  be  sterile,  as  the  examinations  both  by  Gram's  reagent 
and  cultures  are  negative. 

When  ulceration  is  about  to  take  place,  small  white  eleva- 
tions appear  on  the  tonsil,  which  show  the  following  charac- 
teristics :  The  thin  epithelial  wall  which  lines  the  cyst  is 
destroyed  here  and  there  ;  the  caseous  contents  show 
degenerated  epithelial  cells  ;  the  neighbouring  tonsillar  tissue 
has  undergone  modification,  and  shows  necrotic  islets  sur- 
rounded by  inflammatory  tissue,  with  engorged  vessels. 

Numerous  streptococci  and  staphylococci  are  found  by 
Gram's  method. 

In  transverse  section  the  ulcer  is  seen  as  a  notch,  in  which 
the  tonsillar  epithelium  is  wanting.  The  epithelium  at  the 
edges  is  disorganized,  no  cellular  structure  being  definable 
either  here  or  in  the  sclerosed  tonsillar  tissue. 

Bacteriological  examination  in  these  ulcerative  forms 
shows  the  presence  of  streptococci,  diplococci,  fusiform 
bacilli,  and  others. 

Course — Duration — Termination. — This  ulceration,  as  a  rule, 
progresses  similarly  to  that  of  a  wound  made  by  the  cautery. 
After  a  duration  of  four  to  five  days  it  begins  to  heal  from  the 
edge  and  base,  and  eventually  appears  as  a  large  sinuous 
cicatrix.  In  some  cases  the  author  has  seen  the  centre  of  the 
tonsil  cut  out,  as  if  morcellement  had  been  performed.  It  is 
thus  a  localized  benign  gangrene.   Recurrences  are  exceptional. 

Diagnosis. — This  should  be  simple.  It  should  not  be  mis- 
taken for  acute  tuberculosis  of  the  tonsil,  there  being  no 
resemblance  in  appearance,  symptoms,  or  course. 

In  chronic  tuberculosis  (lupus)  the  borders  of  the  ulcer  are 
always  red  and  infiltrated,  and  become  lost  by  degrees  in 
the  healthy  tissue.  The  ulceration  is  not  deep,  and  we  have 
the  development  of  pink  nodules.  Lastly,  its  growth  is  by 
successive  stages,  and  of  long  duration. 

As  regards  malignant  tumours,  diagnosis  is  easy,  as  in 
carcinoma  we  see  the  general  tonsillar  swelling  and  the 
characteristic  glandular  involvement.  Mucous  patches  are 
more  superficial,  diffuse,  and  more  lasting  than  the  simple 


PATHOLOGY  OF  THE  PHARYNX  29 

ulcer.  On  the  other  hand,  ulcerated  gummata  simulate 
slightly  this  affection  from  their  carbuncle-like  appearance. 
Their  base  shows  a  bleeding,  fungous-like  reddish  surface  ; 
but  they  are  irregular  in  shape,  often  multiple,  the  borders 
being  red  and  infiltrated,  and  not  well  defined.  The  ulcera- 
tion attacks  as  well,  and  even  by  preference,  the  pillars  and 
the  posterior  pharyngeal  wall.  Further,  the  course  of  the 
disease,  with  its  characteristic  cicatricial  synechise,  would 
make  the  diagnosis  certain. 

The  prognosis  is  favourable. 

Treatment. — Our  aim  should  be  to  keep  the  parts  as  clean 
as  possible  by  using  antiseptics.  A  solution  of  zinc  chloride 
on  a  cotton-wool  mop  is  applied  to  the  parts. 

}^  Hydrochloride  of  cocaine  25  centigrammes  gr.  7I 

Zinc  chloride  ...              ...       i  gramme  gr.  30 

Hydrochloric  acid           ...       ^  drop  vf[  i 

Pure  glycerine                  ...  10  grammes  3iv 

Distilled  water                 ...  10  to  20  grammes  3v  to  x 

An  alkaline  gargle  and  borated  solutions  are  also  suggested. 

^  Biborate  of  soda  ^  __  ^  (  3iss 

_,  r       -,    r  ...    aa  0  grammes  -,  _. 

Benzoate  01  soda;  t  oiss 

Tincture  of  eucalyptus  ...     10  grammes    lT]^clx 

Glycerine  (neutral)     ...  ...    150  grammes        giv 

A  teaspoonful  added  to  a  glass  of  tepid  water  should  be 
used  as  a  mouth-wash  several  times  a  day. 

If  the  ulcer  does  not  show  signs  of  rapid  healing,  we  may 
paint  the  surface  after  forty-eight  hours  with  a  solution  of 
zinc  chloride. 

General  tonic  treatment  and  light  diet  (milk,  eggs,  with 
Vichy  or  alkaline  water)  are  highly  recommended.  Smoking 
should  be  prohibited,  till  cure  has  taken  place,  which  should 
not  be  long,  provided  that  the  treatment  is  regularly  and 
scrupulously  carried  out. 

Ulcero-membranous  Angina. 

An  inflammation  of  the  pharyngeal  cavity,  resembling 
stomatitis.     It  is  also  known  as  Vincent's  angina. 


so  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

Etiology. — It  occurs  more  frequently  in  males  from  eighteen 
to  thirty,  and  in  children  it  is  less  rare  than  is  supposed.  It 
appears  specially  in  subjects  who  are  debilitated  from  what- 
ever cause. 

Symptoms. — This  ulcero-membranous  tonsillitis  may  occur 
along  with  or  apart  from  stomatitis.  Its  onset  is  marked 
by  slight  fever,  general  fatigue,  and  a  feeling  of  uneasiness, 
rather  than  by  pain  in  the  throat. 


Fig.  8. 


-Appearance  of,  the  Tonsils  and  the  Pillars  in  a  Case  of 
Ulcero-membranous  Tonsillitis. 


On  examination,  a  false  membrane,  white  or  greyish-white 
in  colour,  is  seen,  the  edges  of  which  are  slightly  prominent 
and  surrounded  by  a  well-defined  inflammatory  zone.  The 
tissues  in  the  immediate  neighbourhood  are  red  and  in- 
flamed. Underneath  this  membrane  there  is  an  eroded, 
easily-bleeding  surface.  This  is  situate  not  only  on  the  tonsil, 
but  also  on  a  part  of  the  anterior  or  posterior  pillars,  and  may 
even    spread   to    the    palate   and  uvula.     The  submaxillary 


PATHOLOGY  OF  THE  PHARYNX  31 

glands  and  those  at  the  angle  of  the  jaw  become  swollen,  but 
not  very  painful.  If  the  progress  is  not  checked,  a  profound 
invasion  of  the  tissues  takes  place,  with  the  formation  of 
deep  ulcers  with  irregular,  sometimes  bevelled,  edges.  The 
base  is  covered  with  a  pseudo-membrane  of  a  reddish-grey 
colour.  When  this  is  raised  a  granular  surface  is  exposed, 
which  bleeds  easily.  This  membrane  generally  becomes  re- 
produced when  removed.  It  is,  indeed,  a  gaiigrenoiis  process, 
originating  on  the  surface  and  penetrating  downwards.  The 
tonsil  thus  infected  is  inflamed,  as  well  as  the  palate  and 
pillars.  The  breath  is  fetid,  and  the  glandular  swelling  is 
considerable  and  painful  to  the  touch.  There  is  little  or  no 
fever,  the  temperature  thus  being  not  proportional  to  the 
local  and  general  symptoms.  Along  with  this  there  is  a 
feeling  of  fatigue  and  disinclination  to  work,  and  dysphagia, 
especially  if  both  tonsils  are  involved. 

Course — Duration — Termination. — The  course  of  this  affec- 
tion is  fairly  slow.  It  may  be  prolonged  for  weeks,  if  the 
sufferer  is  debilitated,  etc.,  but  under  favourable  conditions 
it  usually  resolves  in  from  eight  to  fifteen  days. 

Recurrences .  are  not  extremely  rare,  recovery  usually 
taking  place.  The  author  has  seen  cases  where  the  tonsils 
became  almost  completely  sphacelated.  This  has  also  oc- 
curred in  children  on  the  uvula  and  a  portion  of  the  palate. 

The  prognosis  is  generally  favourable,  but  fatal  results  have 
occurred  in  children.  It  is  important  to  know,  if  in  those 
cases  there  was  no  diphtheria  present,  or  ulcero- mem- 
branous tonsillitis  accompanied  by  stomatitis  of  the  same 
nature.  Bacteriological  research  demonstrates  the  existence 
of  numerous  fusiform  bacilli,  with,  in  most  cases,  a  spirillum, 
along  with  other  micro  -  organisms,  as  the  streptococcus, 
diplococcus,  coli  bacillus,  etc.  It  thus  in  appearance,  both 
pathologically  and  bacteriologically,  resembles  ulcero-mem- 
branous  stomatitis,  of  which  it  is  the  tonsillar  form. 

In  most  cases  the  author  has  not  found  diphtheria  bacilli. 

Diagnosis. — This  form  is  often  mistaken  for  acute  ulcerous 
lacunar  tonsillitis.  The  former  originates  and  spreads  from 
the  surface  downwards,  while  the  other,  on   the  contrary. 


32  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

spreads  from  within  outwards.  As  regards  site,  ulcero- 
membranous tonsillitis  is  localized  partly  on  the  tonsil, 
pillars,  and  palate.  In  ulcerous  tonsillitis  the  adjacent  area 
is  not  inflamed,  but  is  so  in  the  ulcero-membranous  variety. 
Finally,  the  co-existence  of  ulcers  in  the  mouth,  on  the 
lips  and  gums,  suggests  the  ulcero-membranous  form. 

Treatment. — Seeing  the  analogy  between  these  two  forms, 
one  would  be  inclined  to  treat  them  on  the  same  lines. 
Chlorate  of  potash  the  author  considers  the  most  rational 
remedy  to  be  given,  both  externally  and  internally.  It  may 
be  used  in  the  form  of  a  gargle  or  as  a  lozenge.  The 
patient  should  be  placed  in  healthy  surroundings.  A  tea- 
spoonful  of  bicarbonate  of  soda  to  ^  litre  of  water,  to  which 
some  '  alcool  de  menthe,'  or  other  aromatic,  may  be  added, 
is  useful  as  a  mouth-wash.  Oxygenated  water,  or,  still 
better,  boro-oxygenated  water,  12  volumes  being  mixed  with 
three-fourths  of  boiled  water,  also  makes  an  excellent  anti- 
septic ;  so  does  a  formaline  solution,  i  to  5,000. 

A  mouth-wash  may  be  as  follows  : 

R  Biborate  of  soda  }  __     ^  f  gr.  75 

r    ...     aa    5  grammes      \        i^ 

Benzoate  of  soda  ;  <  g^"-  75 

Sterilized  water     ]  __     ^  f      3iv 

'    ...     aa  15  grammes      <  _••• 
Pure  glycerme        )  (,  oHiss 

This  is  a  most  useful  application. 

Chlorate  of  potash  is  a  wonderful  specific,  but  must  be 
used  with  prudence,  as  otherwise  it  may  become  irritating. 

Pseudo-membranous  Angina,  Non-diphtheritic. 

An  inflammation  of  the  throat  associated  with  the  formation 
of  false  membranes,  but  without  the  presence  of  the  Klebs- 
Loeffler  bacillus. 

Etiology. — This  affection,  known  for  a  long  time  as  diph- 
theroid angina,  is  far  from  rare,  and  is  similar  in  its  etiology 
to  the  other  inflammatory  affections  of  this  region.  It  is 
the  result  of  cold,  of  surgical  traumatism  of  the  tonsils,  or 
of  organs  more  remote,  as  in  the  nasal  fossae,  of  debility,  and 


PATHOLOGY  OF  THE  PHARYNX  33 

sometimes  contagion.  Some  of  these  anginas  are  secondary. 
Rarely  seen  in  small-pox,  it  is  more  common  in  measles, 
and  especially  in  scarlet  fever,  either  at  the  beginning  of  the 
disease  or  during  convalescence,  and  it  generally  assumes  a 
malignant  course.  Bacteriologically,  there  may  be  found 
pyogenic  streptococci,  staphylococci,  pneumococci,  or  even 
the  common  Bactermm  coli,  either  isolated  or  associated  with 
other  microbes.  No  special  microbe  exists  for  this  par- 
ticular form  of  inflammation. 

Symptoms, — Primary  or  secondary  diphtheroid  angina  has 
a  well-marked  onset — fever,  rigors,  with  the  development  of 
a  yellowish  pseudo-membranous  exudation  over  the  tonsils, 
invading  the  pillars,  soft  palate,  and  uvula.  This  membrane 
is  buff-coloured  and  thick,  and  can  be  readily  stripped  off  in 
a  single  piece,  showing  a  mould  of  the  tonsils,  etc.  The 
mucous  membrane  underneath  is  red,  inflamed,  and  swollen, 
but  there  is  no  ulceration.  Regrowth  of  the  false  membrane 
may  take  place,  but  it  is  thinner  and  less  extensive  than  the 
original  exudation.  Locally  the  patient  complains  principally 
of  dysphagia,  with  slight  pain,  '  snuffling,'  and  on  swallowing 
fluid  often  regurgitation  from  the  nose.  The  breath  is  fetid 
and  the  submaxillary  glands  swollen,  specially  with  children. 
This  symptom  is  less  pronounced  than  in  true  diphtheria. 

The  general  condition  is  fairly  well  maintained.  Among 
unweaned  children  we  frequently  observe  grave  symptoms — 
nasal  discharge,  great  prostration,  with  rise  of  temperature, 
even  resulting  in  death. 

Course. — This  non-diphtheroid  affection  is  usually  rapid  in 
its  course,  the  febrile  phenomena  disappearing  in  twenty- 
four  to  forty-eight  hours.  In  a  week  the  disease  abates. 
Examination  at  this  period  shows  redness,  with  diminished 
movement  of  the  uvula.  Sometimes,  however,  slight  paresis 
occurs  on  one  or  both  sides. 

Complications. — Though  usually  conflned  to  the  pharynx, 
the  exudation  may  pass  upwards  into  the  nasal  fossae,  or 
downwards  and  attack  the  aryepiglottic  folds.  The  most 
frequent  complication  is  the  adeno-phlegmon  or  retro- 
pharyngeal abscess. 

3 


30  centigrammes 

gr-5 

2  grammes 

gr.  30 

10  drops 

TT(_X 

1.5  grammes 

3iii 

34  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

Diagnosis. — This  is  usually  easy.  The  membrane  is  thicker 
and  more  leathery  than  that  seen  in  true  diphtheria.  Bac- 
teriological examination  determines  the  diagnosis. 

Treatment  consists  in  keeping  the  part  aseptic  by  means 
of  alkaline  washes  of  borate  or  bicarbonate  of  soda — i  tea- 
spoonful  to  i  litre  of  tepid  water.  The  false  membrane 
should  be  removed  early,  and  the  affected  parts  painted  over 
with  the  following  once  or  twice  a  day  without  rubbing  : 

Ç:  Hydrochloride  of  cocaine  ... 
Salicylate  of  soda 
Spirit  of  peppermint  ('  alcool 

de  menthe')     ... 
Glycerine 

A  general  mild  tonic  treatment  is  also  recommended  as 
soon  as  the  inflammatory  symptoms  have  disappeared. 

Diphtheritic  Angina. 

An  inflammation  of  the  pharynx  due  to  the  Klebs- 
Loeffler  bacillus,  accompanied  by  symptoms  of  general 
infection  from  the  absorption  of  the  toxin  generated  there. 

Etiology.— Klebs  in  1883,  and  Loeffler  in  1884,  demon- 
strated that  this  disease  was  due  to  a  bacillus,  which  has 
received  their  name.  Besides  causing  the  exudation  it  also 
produces  a  toxin,  which,  becoming  absorbed,  gives  rise  to 
systemic  poisoning.  In  addition  to  this  Klebs  -  Loefller 
bacillus,  we  find  the  presence  of  other  microbes,  which 
intensif}^  or  modify  the  nature  of  the  disease. 

The  specific  organism  is  rod-shaped,  straight  or  curved, 
twice  as  large  and  of  a  length  equal  to  that  of  the  tubercle 
bacillus.  In  order  to  recognize  it,  it  is  necessary  to  cultivate 
it  on  gelatinized  serum  in  the  following  manner  :  Take  a 
small  metal  probe  with  a  flattened  point  ;  heat  it  to  redness 
over  a  lamp.  When  cold,  rub  lightly  over  the  inflamed 
area,  to  obtain  a  portion  of  the  membranous  exudation, 
and  introduce  the  probe  into  the  sterilized  gelatinized 
serum.  Close  the  orifice  of  the  tube  with  cotton-wool,  which 
is  first  singed  to  prevent  contamination,  and  place  it  in  a 


PATHOLOGY  OF  THE  PHARNYX  35 

dr3àng-chamber  at  37^  C.  for  seventeen  to  eighteen  hours. 
Little  greyish-white  colonies,  with  opaque  centres,  are  then 
seen  coming  to  the  surface.  A  portion  of  this  is  taken  and 
stained  with  Loeffler's  blue,  when  the  characteristic  bacillus 
is  recognized.  The  longer  the  bacillus,  the  more  virulent  is 
the  disease,  according  to  some  authors. 

The  combination  of  Loeffler's  bacillus  with  other  patho- 
genic bacteria  constitutes  always  a  graver  prognosis.  The 
best- method  of  estimating  the  exact  degree  of  virulence  of 
these  pathogenic  organisms  is  to  inoculate  pure  cultures  into 
the  guinea-pig,  when  death  usually  occurs  in  thirty  to  forty 
hours  from  diphtheria. 

The  chemical  nature  of  the  toxin  is  not  yet  clearly  known, 
whether  a  tox-albumin  or  a  nucleo-albumin.  Whatever  it  is, 
it  is  known  that  diphtheria  is  an  infectious,  epidemic,  and 
contagious  disease,  which  confers  no  immunity,  and  which 
specially  attacks  children.  It  is  contagious  before  the 
appearance  of  the  false  membranes,  and  continues  so  for 
some  time  after  they  have  completely  disappeared. 

If  a  bacteriological  examination  be  made  a  month  or  two 
after  the  apparent  recovery,  the  characteristic  bacilli  can  be 
seen.  The  contagion  may  be  spread  in  many  wa3's — by  the 
air,  hands,  bedding,  garments,  the  false  membranes,  etc. 
The  soil  has  an  important  bearing  on  its  development  and 
prognosis.  Children,  if  placed  in  bad  hygienic  surroundings, 
are  more  liable  to  be  attacked  by  virulent  types. 

Symptoms. — We  may  look  upon  this  disease  as  having  two 
types  :  one  a  benign  form,  which  is  mono-microbian,  and 
the  other — graver  or  toxic  cases — bacillo-coccic,  strepto- 
coccic, etc. 

A.  The  Benign  Anginous  Type. 

The  onset  of  diphtheritic  angina,  whatever  its  form,  is 
usually  insidious,  with  an  incubation  period  of  live  to  eight 
days.  There  is  often  a  feeling  of  malaise,  fever,  loss  of 
appetite,  headache,  diarrhœa — in  a  word,  the  signs  of  a 
general  infection.  A  few  days  after  this  the  child  complains 
of  slight  sore  throat,  and  although  the  pain  is  not  severe, 

3—2 


36  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

yet  the  cervical  submaxillary  glands  are  already  swollen. 
The  general  symptoms  now  rapidly  become  worse  :  the 
patient  is  pale  and  fatigued,  and  the  appetite  almost  entirely 
lost.  The  fever  is  constant,  though  moderate.  The  voice 
becomes  nasal,  tonsillar,  sometimes  even  croup  -  like.  In 
other  cases  the  attack  may  be  very  sudden,  with  high  fever, 
shivering,  convulsions,  and  even  delirium,  followed  by  the 
development  of  the  false  membrane.  This  type  is  frequently 
mild. 

Examination  of  the  throat  during  the  early  stage  shows 
a  slight  redness.  Twenty-four  or  forty-eight  hours  later, 
a  thin,  greyish -white,  pellicular  spot  appears,  which,  on 
being  stripped  off,  leaves  a  bleeding,  non-ulcerated  surface. 
This  false  membrane  is  reproduced  very  rapidly,  and 
spreads  more  extensively  over  the  surface.  At  other 
times  isolated  patches  over  the  tonsils  coalesce  and  form 
a  dirty-grey  exudation,  which  may  extend  over  the  pharynx, 
base  of  tongue,  epiglottis,  the  aryepiglottic  folds,  and  even 
into  the  larynx.  The  patient  may  now  convalesce,  or  general 
toxaemia  may  supervene.  If  the  membrane  has  spread  down  to 
the  larynx,  the  characteristic  symptoms  of  croup  appear.  In 
mild  cases,  the  urine  does  not  contain  albumen  ;  but  if  toxaemia 
takes  place,  albuminuria  may  be  present  in  this  benign  form. 

B.  Infectious  Polymicrobian  Type  of  Angina. 

The  onset  may  resemble  that  seen  in  the  benign,  but  the 
general  phenomena  are  much  more  intense.  Albuminuria 
appears  very  early.  The  false  membrane  has  a  tendency  to 
invade  the  neighbouring  parts  (the  nasal  fossse,  larynx, 
mouth,  etc.).  Regurgitation  of  fluids  with  great  fetor  occurs, 
along  with  pronounced  cervical  and  submaxillary  adenitis. 

The  course  may  be  rapid,  and  the  child  die  in  spite  of 
any  specific  treatment.  The  quantity  of  albumen  is  found 
on  analysis  to  be  very  considerable,  and  the  depression 
is  great.  The  throat  may  show  very  slight  local  lesions 
in  these  cases  ;  the  voice  is  altered,  the  cough  is  croupy,  and 
bronchitic  râles  are  heard.     These  may  resemble  ambulatory 


PATHOLOGY  OF  THE  PHARYNX  37 

typhoid    cases,    the    patient    dying    from    the    diphtheritic 
virus. 

Pathology. — The  signs  of  a  grave  systemic  poisoning  are 
present,  the  blood  black,  coagulating  badly  after  death,  and 
containing  a  large  number  of  white  globules.  The  spleen  is 
enlarged,  the  liver  congested,  and  both  infiltrated  with  round 
cells.  The  hepatic  cells  are  overladen  with  fat.  The  kidney 
shows  acute  imflammatory  lesions.  The  endothelial  cells  of 
the  capsule  are  swollen  with  exudation  between  the  capsule 
and  the  glomerulus,  with  marked  desquamation  in  the  con- 
voluted tubules.  There  is  great  infiltration  of  white  globules 
along  the  straight  tubules  and  the  vessels.  The  heart  is 
dilated,  and  shows  muscular  degeneration.  In  the  nervous 
system  acute  myelitis  of  the  anterior  horns  is  met  with,  and 
particularly  peripheral  neuritis.  The  paralyzed  muscles 
undergo  granular  and  fatty  degeneration. 

Complications. — When  the  exudation  reaches  the  larynx,  it 
constitutes  what  is  known  as  croup.  The  skin  may  be  also 
affected,  and  present  a  scarlatiniform  erythema  purpura  or 
ecchymosis.  Glandular  swelling  and  arthritis  may  be  pre- 
sent.    Acute  myocarditis  may  cause  death  through  syncope. 

Albuminuria  is  so  frequent  a  complication  of  grave 
diphtheria,  that  it  may  be  looked  upon  as  a  symptom. 
Finally,  it  must  be  remembered  that  diphtheria  occasionally 
attacks  the  nervous  system,  the  muscles  of  the  throat,  soft 
palate,  œsophagus,  or  tongue,  etc.  The  ocular  muscles  are 
frequently  affected,  likewise  the  organs  supplied  by  the  vagus. 

Course. — Its  duration  depends  greatly  on  the  nature  of  the 
bacillus,  on  the  power  of  resistance  of  the  individual,  and 
also  on  the  nature  of  the  treatment.  Convalescence  is 
usually  long,  and  the  patient  should  be  kept  under  observa- 
tion, as  death  from  sudden  syncope  may  take  place. 

Prognosis. — This  should  be  guarded.  Besides  the  presence 
of  the  local  manifestations,  the  existence  of  toxaemia  must 
be  remembered,  and  the  possible  complications  which  are 
liable  to  occur  suddenly  when  least  expected.  Since  the 
serum  treatment  has  been  introduced,  the  prognosis  has  been 
greatly  altered  for  the  better. 


38 


DISEASES  OF  THE  PHARYNX  AND  LARYNX 


Diagnosis. — Though  it  is  difficult  in  many  cases  to  diagnose 
diphtheritic  infection,  yet  bacteriological  examination  makes 
the  diagnosis  much  easier.  The  author  is  of  opinion  that  the 
clinician  should  not  only  base  his  diagnosis  on  the  result  of 
the  bacteriological  examination,  but  also  on  the  course  of  the 
disease,  and  the  general  and  local  symptoms,  and  in  this 
manner  he  will  be  enabled  to  establish  with  some  degree  of 
certainty  the  diagnosis,  as  well  as  the  gravity  of  the  disease. 

Treatment. — This  is  much  simplified  since  the  introduction 
of  Roux's  serum  mto  therapeutics.     x\s  soon  as  diagnosis  is 


Fig.  9. — Froix's  Tubes,  with  Introducer  and  Extractin'g  Hook. 

established  by  clinical  and  bacteriological  data,  isolate  the 
patient,  place  him  in  a  well-lighted  room,  and  by  means  of 
carbolized  steam  vapour,  to  which  some  oil  of  eucalyptus 
is  added,  produce  a  humid  atmosphere.  The  strength  of  the 
child  must  be  maintained  against  the  intoxication. 

Locally,  a  mouth-wash  may  be  given,  such  as  a  weak 
carbolic  or  alkaline  solution.  On  the  first  indication  use 
antitoxic  serum.  It  should  be  given  as  early  as  possible.  If 
used  at  the  beginning,  a  dose  of  10  to  20  c.c,  according  to 
age,   will  be    sufficient  ;    but   if  later,   when    intoxication   is 


PATHOLOGY  OF  THE  PHARYNX  39 

already  pronounced,  larger  doses  must  be  employed. 
Certain  authors  even  advise  in  young  children  of  a  few 
months  to  a  year  old  the  use  of  20,  30,  or  even  40  c.c.  As 
a  general  rule,  it  is  advisable  to  inject  i  c.c.  for  every  month 
up  to  two  years  of  age.  These  injections  must  be  made 
aseptically,  sterilizing  the  skin  and  instruments.  The  effect 
of  the  injection,  if  given  early,  is  rapid,  the  general  state  of 
the  child  improving,  false  membranes  becoming  detached, 
and  convalescence  hastened.  Since  the  introduction  of  this 
treatment  the  mortality  has  greatly  decreased — at  least,  when 
the  serum  has  been  early  employed — so  that  now  diphtheria 
is  not  looked  upon  with  such  dread  as  it  formerly  was. 
Sero-therapy  is  undoubtedly  the  best  treatment  for  post- 
diphtheritic paralysis. 


Fig.  10. — O'Dwyer's  Gag. 

As  a  result  of  this  sero-therapy,  polymorphic  or  scar- 
latiniform  erythemata,  joint  affections,  circulatory  or  urinary 
troubles,  have  followed,  but  they  are  of  no  consequence.  It 
is,  however,  well  to  note,  that  there  are  some  cases  of 
malignant  hypertoxic  diphtheria  on  which  the  serum  does 
not  appear  to  have  any  such  curative  effect.  It  is  possible 
that  in  these  cases  the  sero-therapy  was  used  too  late. 

If  respiration  is  endangered  in  consequence  of  the  extension 
of  the  false  membrane  to  the  larynx,  intubation  should  with 
out  exception  be  performed  rather  than  tracheotomy.  "  An 
experienced  assistant  should  always  be  in  immediate  attend- 
ance, ready  to  replace  the  tube,  if  ejected  through  coughing. 
The  tube  is  introduced  by  a  special  instrument  guided  by 
the  surgeon's  index-finger,  and  is  passed  into  the  larynx,  the 


40 


DISEASES  OF  THE  PHARYNX  AND  LARYNX 


epiglottis  being  at  the  same  time  raised.  The  extraction  of 
the  tube,  which  should  not  remain  in  situ  for  more  than  four 
to  five  days,  is  effected  by  pressure  on  the  thyroid  cartilage 
from  below  upward,  or  by  means  of  a  special  hook. 


Fig.   II. — Instrument  fop.  Introducing  Tubes. 

Tracheotomy  is  recommended  in  those  cases  where  the 
patient  is  at  a  distance  from  the  doctor,  when  there  is 
any  chance  of  approaching  asphyxia.  The  opening  should 
be  made  below  the  cricoid,  so  as  to  avoid  consequent 
stenosis. 


Fig.   12, — O'Dwyer's  Tubes. 


Tonsillar  and  Peritonsillar  Abscess. 

An  acute  inflammation  terminating  in  suppuration  of,  the 
tonsil,  of  the  cellular  tissue  around  it,  or  of  both  simul- 
taneously. 

Etiology. — Peritonsillar  abscesses  are  more  frequent  than 
suppuration  in  the  gland  itself.  The  causes  of  both  are 
identical.     The  author  has  found,  that  abscess  of  the  tonsil 


PATHOLOGY  OF  THE  PHARYNX  41 

is  most  frequent  in  early  life,  particularly  from  eighteen 
to  thirty,  thus  differing  from  most  authors,  who  consider 
it  more  frequent  in  youth.  It  is  especially  liable  to  occur 
at  certain  changes  of  the  seasons.  The  size  of  the  tonsil 
does  not  appear  to  affect  the  development  of  the  disease  ; 
on  the  contrary,  the  crj^pts,  deep  and  constricted  at  their 
orifices,  tend  to  favour  it.  Any  debilitating  cause,  such  as 
overwork,  excessive  fatigue,  etc.,  predisposes  to  this  affec- 
tion. Although  the  infection  usually  comes  from  without, 
it  is  quite  probable,  as  Professor  Bouchard  has  pointed 
out,  that  the  infection  may  also  be  carried  from  the 
blood-stream.  Cold  ma}-  act  as  an  exciting  cause,  either 
directly  or  indirect!}-,  through  the  vasomotor  system.  Among 
other  causes  we  have  inflammations  of  the  nasal  fossae, 
especially  suppuration  of  the  accessory  sinuses  and  the 
after-effect  of  the  use  of  the  cautery. 

On  section  a  great  infiltration  of  embryonic  cells  is  seen 
lying  in  the  submucosa  of  the  tonsil  and  the  surrounding 
tissues.  Streptococci,  staphylococci,  and  pneumococci  are 
present. 

Symptoms. — These  vary  much  in  their  intensity.  The 
patient  complains  of  slight  inconvenience  in  one  side  of 
the  throat,  followed  by  pain  during  deglutition.  Accom- 
panying this  we  have  the  general  phenomena  of  fever — 
headache,  loss  of  appetite,  with  coated  tongue,  and  often 
accompanied  by  constipation.  If  this  affection  is  not 
arrested  at  this  period  the  general  symptoms  increase,  with 
shivering,  the  voice  becoming  muffled  from  the  partial  or 
total  immobility  of  the  soft  palate.  Pain  is  now  constant, 
and  may  be  so  severe  as  to  cause  the  patient  to  refuse  food. 
The  saliva,  which  is  thick  and  fetid,  flows  from  the  mouth, 
owing  to  the  pain  and  difficulty  of  swallowing  from  the 
tumefaction.  In  many  cases  regurgitation  occurs  through 
the  nose,  and  the  glands  at  the  angle  of  the  jaw  are 
swollen  and  painful  to  the  touch,  particularly  on  the  affected 
side. 

We  may  divide  these  abscesses  clinically  into  two  forms  — 
(i)  intratonsillar  abscess  ;  (2)  peritonsillar  abscess. 


42  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

I.  Intratonsillar  Abscess. 

On  examination  in  the  earlier  stages,  the  tonsil,  along  with 
the  mucous  membranes  covering  the  anterior  pillar  and  the 
soft  palate,  are  seen  to  be  congested  and  slightly  swollen. 
The  affected  tonsil  rapidly  becomes  larger  and  of  a  deeper 
colour,  and  frequently  a  yellowish-white  area  of  suppuration 
is  seen.  Fluctuation  can  sometimes  be  felt  by  the  finger. 
If  evacuation  of  the  pus  does  not  now  take  place,  it  will 
invade   the  deep  mass  of  the  tonsils,  and  the  peritonsillar 


Fig.  13. — Appearance  of  the  Pharyngeal  Cavity  in  a  Case  of  an 
r-'-^.^-   Antero-su.perior  Peritonsillar  Abscess. 

tissue  is  inflamed  in  its  turn,  the  tonsils  being  covered  with 
a  whitish  coating.  The  tongue  is  furred,  the  jaws  are  locked, 
the  pain  is  intense,  even  shooting  up  to  the  ears.  Swallowing 
is  so  painful,  that  the  saliva  is  allowed  to  dribble  from  the 
mouth. 

2.  Peritonsillar  Abscess. 
1 .  Anterior. — This  is  the  most  frequent  form  of  abscess, 
and  is  situate  in  the  cellular  tissue  of  the  posterior  part  of 


PATHOLOGY  OF  THE  PHARYNX  43 

the  anterior  pillar  above  the  tonsil.  At  first  the  redness  and 
swelling  are  situate  over  the  superior  part  of  the  anterior 
pillar  ;  later  the  free  border  of  the  palate  becomes  involved 
and  projects  forwards,  while  the  tonsil  itself  is  more  or  less 
pushed  backwards  by  the  swelling. 

The  diagnosis  of  this  antero-superior  abscess  is  easy,  since 
it  bulges  at  the  superior  and  internal  edge  of  the  anterior 
pillar. 

2.  Posterior. — This  form  is  not  so  rare  as  one  would 
at  first  suppose.  At  an  earl}^  stage  it  may  be  confused  with 
a  retropharyngeal,  and  later  with  the  antero-superior  abscess, 
with  which  it  blends.  At  first  the  congestion  and  swelling 
are  clearly  limited  to  the  posterior  pillar,  which  becomes 
rounded  and  smooth,  pushing  the  tonsil  in  front  of  it.  Later 
on  the  palate  becomes  infiltrated.  The  anterior  pillar  is  abso- 
lutely healthy.     The  tonsil  is  only  slightly  congested. 

3.  External. — While  the  external  peritonsillar  abscess 
is  less  frequent  than  the  preceding  forms,  it  is,  however,  the 
more  serious.  In  this  form  the  tissues  of  the  heck  are  more 
swollen  than  in  the  preceding,  with  inclination  of  the  head 
to  one  side  and  difficulty  of  opening  the  mouth.  The 
general  symptoms  are  of  extreme  gravity,  insomnia  and 
delirium  being  concomitants.  The  parotid,  submaxillary, 
and  occipital  glands  become  rapidly  infiltrated.  In  a  word, 
the  affection  appears  to  be  more  external  than  internal.  On 
examination  of  the  pharynx,  the  tonsils  are  seen  to  be  pro- 
jected into  the  middle  line,  but  are  not  inflamed.  The 
palate  and  uvula,  with  the  anterior  pillar,  may  be  cedematous, 
but  are  often  unaffected.  On  the  other  hand,  there  are 
swelling  and  congestion  inside  the  tonsillar  fossa.  The 
back  of  the  throat  is  painful  to  touch,  but  less  so  than  the 
external  parts.  The  pus  may  find  its  way  and  escape 
through  the  pharyngeal  aponeurosis  round  the  vasculo- 
nervous  bundle  constituting  a  lateral  pharyngeal  phlegmon. 

4.  Inferior. — This  abscess  is  situate  below  the  tonsil, 
between  it  and  the  lingual  tonsil,  behind  the  anterior  pillar 
towards  its  base.  By  the  tonsil  its  growth  is  pushed  up- 
wards on  the  anterior  pillar.      In  this  form  odynphagia  is 


44  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

early  and  severe.  The  tongue  becomes  immobile,  and  infil- 
tration takes  place,  not  only  on  the  lateral  wall  of  the 
pharynx,  but  even  extending  to  the  epiglottis  and  the 
corresponding  aryepiglottic  folds.  If  the  pus  gravitates 
laterally,  it  constitutes  a  lateral  pharyngeal  abscess,  well 
known  for  its  exceptional  gravity. 

The  author  is  of  opinion,  that  pus  is  found  in  these  cases 
very  early  in  or  round  the  inflamed  tonsil,  even  forty-eight 
hours  after  the  first  symptoms.  Towards  the  fourth  or  fifth 
day  the  diagnosis  can  clearly  be  made  out.  From  this 
period  the  disease  may  be  considered  under  two  aspects, 
according  to  whether  it  be  treated  or  left  to  itself.  If  treated 
early  the  abscess  may  be  cured  in  from  four  to  six  days  ; 
whereas  if  not,  it  will  take  from  eight  to  twelve  days  before 
evacuation  takes  place. 

Complications. — Though  always  resulting  in  recovery,  com- 
plications may  arise.  Among  those  we  may  note  oedema  of 
the  surrounding  parts,  and  this  especially  if  the  abscess  be 
situate  inferiorly.  Icterus,  rheumatism,  septic  pneumonia, 
and  meningitis  also  occur,  though  infrequent.  Breton  records 
a  case  of  phlebitis  of  the  internal  jugular  vein. 

Discharge  of  pus  into  the  larynx  may  have  fatal  results  by 
inducing  asphyxia  before  tracheotomy  can  be  performed. 
Haemorrhage,  arterial  or  venous,  is  the  most  serious 
accident  that  can  take  place.  This  may  occur  spon- 
taneously from  ulceration  into  the  vessels,  or  be  traumatic 
during  the  opening  of  the  abscess. 

The  prognosis  is  generally  benign,  apart  from  those  cases 
where  the  above-mentioned  complications  take  place. 

Diagnosis. — -There  may  be  some  doubt  in  diagnosing  this 
affection  during  the  early  period  of  congestion,  but  later  on 
the  diagnosis  is  easy,  when  we  can  differentiate  whether  the 
tumefaction  is  in  the  tonsillar  recess  or  the  tonsil  itself. 

Treatment. — At  the  onset  the  prevention  of  abscess  forma- 
tion may  be  attempted  by  painting  the  parts  with  a  solution 
of  chloride  of  zinc  (i  :  15  or  i  :  20)  or  tincture  of  iodine.  A 
saline  purge,  emollient  gargles  (hot  or  iced),  salol,  and  the 
application  of  hot  poultices  or  ice  to  the  neck  may  be  pre- 


PATHOLOGY  OF  THE  PHARYNX 


45 


scribed.  If  after  the  lapse  of  twenty-four  to  forty-eight 
hours  improvement  does  not  set  in,  the  author  prefers  a 
speedy  resort  to  surgical  intervention,  but  does  not  approve 
of  the  bistoury,  for  the  following  reasons:  that  sometimes 
severe  venous  haemorrhage  may  follow  a  slight  incision,  and 
that  the  hnear  wound  produced  may  close  up,  and  thus  form 
a  new  suppurating  infection,  unless  kept  open  daily  by  the 


Fig.   14. — St.  Clair  Thomson's  Peritonsillar  Dilator. 

passage  of  a  grooved  director.  It  is  only  during  the  later 
stages,  when  the  abscess  is  on  the  point  of  opening,  that  the 
bistoury  is  satisfactory.  The  employment  of  the  discission 
hook  with  the  grooved  director  (Ruault),  or  by  the  method 
so  highly  praised  by  Killian — namely,  the  replacing  of  the 
probe  by  a  forceps  introduced  into  the  subtonsillar  region — is 


Fig.   15. — Fitzgerald's  Peritonsillar  Dilator. 

not  so  efficient  in  the  author's  opinion  during  the  early  stages. 
He  prefers  to  use  in  these  cases  the  thermo-  or,  better  still, 
the  galvano-cautery,  at  a  dull-red  heat.  The  parts  are  first 
painted  with  adrenalin  and  cocaine  (i  :  5),  or  with  a  solution 
of  equal  parts  of  menthol,  carbolic  acid,  and  cocaine  hydro- 
chlorate  (Bonain's  solution).  The  incision  made  is  not 
very  painful ,  there  is  little  or  no  bleeding,  and  as  the  wound 


46 


DISEASES  OF  THE  PHARYNX  AND  LARYNX 


remains  open  from  eight  to  ten  da3's,  the  pus  can  escape 
freely,  and  thus  prevent  septic  retention.  In  those  cases 
where  the  aperture  has  been  made  early  and  no  pus  has 
been  found  at  the  time,  it  is  not  uncommon  to  observe  it  a 
few  hours  later. 

In  the  intratonsillar  cases  the  galvano-cautery  is  to  be 
plunged  into  the  substance  of  the  organ  from  before  back- 
wards, and  the  pus  evacuated.     Where  the  abscess  is  situate 


Fig.  i6. — Appearanxe  of  the  Tonsil  after  the  Opening  of  an 
Antero-superior  Abscess  with  the  Galvano-cautery. 

Site  and  form  of  the  scar  two  or  three  days  after  the  incision.     The  centre  and 
the  edges  are  slightly  more  grej-ish  and  sphacelated. 

antero-superiorl}-,  the  incision  is  to  be  made  over  that  part 
of  the  soft  palate  which  bulges  forwards,  corresponding  to 
the  superior  portion  of  the  tonsillar  fossa,  i  or  2  centimetres 
from  the  edge  of  the  anterior  pillar,  a  spot  well  indicated  by 
Escat,  although  not  in  a  direction  from  before  backwards 
as  he  states,  but  from  within  outwards — i.e.,  in  an  oblique 
direction  towards  the  external  wall  of  the  tonsillar  fossa.  After 
penetrating  the  thickness  of  the  palate,  which  varies  from 
I  to  2h  centimetres,  according  to  the  amount  of  infiltration. 


PATHOLOGY  OF  THE  PHARYNX 


47 


the  peritonsillar  cellular  tissue  is  then  entered.  As  a  rule, 
the  pus  is  easily  found  ;  if  not,  the  grooved  director  should 
be  employed,  and  thrust  in  various  directions  without  fear 
of  rupturing  important  vessels.  Should  haemorrhage  occur 
it  can  easily  be  checked  by  plugging  the  cavity  with  iodoform 
gauze.     If  the  diagnosis  is  correct,  pus  should  appear. 

When  a  posterior  peritonsillar  abscess  is  dealt  with,  the 
incision  should  be  made  into  the  substance  of  the  pillar  in  a 


Fig.  17.— Appearance  of  the  Pharyngeal  Cavity. 

The  red  lines  indicate  the  points  of  incision  :  i ,  The  antero-superior  abscesses  ; 
2,  postero-superior  (posterior  pillar)  ;  3,  intratonsillar  ;  4,  antero-inferior. 
The  incision  should  in  all  cases  be  directed  from  within  outwards. 


direction  from  before  backwards,  and  in  an  oblique  direction 
outwards.  The  opening  should  be  made  almost  in  the  spot 
corresponding  to  the  upper  third  of  the  tonsil.  The  thickness 
of  intervening  tissue  is  thus  less  by  from  ^  to  i  centimetre. 

It  is  much  more  difficult  to  open  an  external  peritonsillar 
abscess,  as  the  pus  is  situate  on  the  pharyngeal  aponeurosis 
towards    the   lateral  wall.     The    infiltration  is  diffuse,   and 


48  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

owing  to  the  proximity  of  large  vessels,  which  are  never- 
theless about  2  centimetres  away,  the  area  is  dangerous. 
The  cautery  knife  should  be  passed  through  the  substance  of 
the  tonsil,  entering  at  its  superior  third,  in  an  oblique  direc- 
tion from  before  backwards  and  from  within  outwards.  If  no 
pus  escapes  at  a  depth  of  2  to  3  centimetres,  the  knife  should 
be  withdrawn  and  the  grooved  director  substituted,  and  by 
pushing  it  in  a  little  below  or  above  the  incision  pus  may 
be  found.  If  not,  it  may  appear  from  twelve  to  twenty- 
four  hours  afterwards.  The  author  has  seen  the  abscess 
evacuated  ten  to  twelve  hours  after  a  true  haemorrhage 
had  occurred  without  causing  alarm.  In  such  a  case  it 
would  have  been  easy  to  check  the  bleeding  by  stuffing 
with  iodoform  or  aseptic  gauze.  Because  of  their  position 
these  abscesses  should  be  opened  early.  In  those  cases 
where  the  patient  cannot  open  his  mouth,  or  if  the  incision 
fails  to  relieve  symptoms,  it  may  be  necessary  to  operate 
externally. 

Finally,  if  the  abscess  is  situate  inferiorly,  the  cautery 
should  be  plunged  between  the  base  of  the  tonsil  and  the 
tongue,  passing  from  within  outwards  through  the  anterior 
pillar.  It  is  well  to  look  at  the  wound  twenty-four  or  forty- 
eight  hours  after,  and  if  there  is  any  exudation,  etc.,  to  remove 
this  obstacle  to  drainage  by  inserting  the  director. 

Chronic  Abscess  of  the  Tonsils. 

This  may  result  from  repeated  inflammatory  attacks  in 
the  epitonsillar  recess,  or  from  the  imperfect  healing  of  an 
abscess  there.  Between  the  pillar  and  the  gland  there  is  a 
cavity,  from  which  pus  exudes.  As  Raoult  has  pointed  out, 
calculi  are  sometimes  found  in  the  abscess. 

Treatment. — This  consists  in  opening  up  the  fistulous  tract, 
and  swabbing  the  surface  over  with  a  solution  of  chloride 
of  zinc  (i  :  15).  A  speedy  cure  is  usually  obtained  in  a  few 
days. 


PATHOLOGY  OF  THE  PHARYNX  49 

Caseous  Lacunar  Tonsillitis. 

A  chronic  inflammation  of  the  tonsil,  characterized  by  the 
presence  of  caseous  masses  in  the  interior  of  the  glands.' 

Etiologv. — Chronic  inflammation  of  these  glands,  with  the 
special  disposition  of  the  crypts,  are  the  causes  of  this 
infection. 

Symptoms. — These  are  very  slight.  Some  patients  com- 
plain of  inconvenience,  or  even  a  pricking  sensation  in  the 
throat,  especially  marked  during  deglutition,  and  of  a  slight 
pain  reflected  in  the  direction  of  the  ears.  A  more  charac- 
teristic symptom  is  the  expulsion  of  yellowish-grey,  cheesy 
masses  on  coughing.  These  caseous  plugs  vary  much  in 
size,  and  are  extremely  fetid.  On  examination  the  crypts 
are  seen  to  be  filled  with  these  caseous  masses.     In  some 


Fig.   i8. — ^Lennox  Browne's  Cutting  Hook. 

cases  the}^  can  only  be  seen  by  displacing  the  anterior  pillar, 
as  they  lie  behind  it  in  the  subtonsillar  fossa.  Calcareous 
matter  may  be  deposited,  and  form  a  tonsillar  stone  of 
various  sizes. 

Treatment. — This  consists  first,  not  only  in  clearing  out 
the  crypts,  but  also  in  avoiding  the  reproduction  of  these 
foreign  bodies.  This  is  done  by  means  of  a  curved  bistoury 
or  special  hooks,  by  which  the  fibrous  septa  between  the  crypts 
are  broken  down  to  form  one  cavity,  which  permits  of  cure. 
If  there  should  be  any  tonsillar  pseudo-hypertrophy,  morcelle- 
ment should  be  practised  with  Ruault's  forceps.  In  those 
cases  where  the  anterior  pillar  is  so  prominent  as  to  hide  the 
affected  part  of  the  tonsil,  the  author  is  in  the  habit  of  in- 
cising the  anterior  pillar  on  its  free  edge  by  the  galvano- 
cautery.  The  lips  of  this  incision  gape  so  as  to  form  a  ^, 
which  enables  one  to  get  at  the  diseased  crypts. 


50  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

^  2 


Q   jigmj 


Fig.  20.— Cutting 
Hook. 


Fig.  21. — RiCARDO  Botey's  Series  of 
Instruments  for  Practising  Dis- 
cission OR  Opening  of  the  Tonsils. 


Encysted  Lacunar  Tonsillitis. 

This  is  in  some  respects  the  result  of  caseous 
tonsilhtis,  and  is  characterized  by  the  retention  with 
encystment  of  the  products  of  secretion  in  the 
tonsillar  crypts. 

Etiology.  —  This  is  similar  to  that  of  caseous 
lacunar  tonsillitis. 

Symptoms. — As  the  result  of  the  occlusion  of  the 
duct,  a  yellowish-white  tumour-like  mass  is  pro- 
duced, varying  in  size  from  a  gooseberry  seed  to  a  small  cherry. 


Fig.  19.  — 
Ra  u  LT  ' s 
Sharp- 

POI NTED 

AND     Cut- 
ting Hook. 


PATHOLOGY  OF  THE  PHARYNX  51 

Hard  to  the  touch,  with  smooth  walls,  it  resembles  very 
much  a  fibroma.  They  are  usually  situated  in  the  upper 
part  of  the  tonsil  (epitonsillar  recess),  but  they  may  be  met 
with  towards  the  middle  or  inferiorly,  where  they  are,  as  a 
rule,  smaller,  probably  owing  to  the  constant  movement  that 
takes  place  there.  These  bodies  may  be  found  elsewhere, 
such  as  in  the  lingual  and  in  the  naso-pharyngeal  tonsil,  and 
were  described  by  Tornwaldt  as  cysts  of  the  pharyngeal 
bursa. 

Symptoms. — These  are  almost  nil.  There  may  be  in  some 
cases  a  prickling  sensation,  but  it  is  usually  on  the  examina- 
tion of  the  throat,  that  one  discovers  these  yellowish-grey 


Fig.  22. — Punch  Forceps  for  the  Right  Side,  and  for  the 
Right  and  Left  Sides. 

masses.  Those  situate  at  the  base  of  the  tongue  can  only 
be  seen  by  laryngoscopic  examination,  or  by  depressing  the 
organ  forcibly.  On  examination  of  the  contents  of  these 
cysts,  they  are  found  to  consist  of  epithelial  débris  and 
leucocytes.  Bacteriologically  they  give  sterile  cultures. 
When  infection  of  these  cysts  takes  place,  there  are  produced 
those  crater-like  ulcers  which  have  already  been  spoken  of 
as  ulcerous  lacunar  tonsillitis. 

Treatment. — This  is  simple,  and  consists  of  opening  the 
cysts  with  the  galvano-cautery,  curetting  the  cavity,  and 
swabbing  over  with  a  solution  of  chloride  of  zinc  (i  :  20  to 
I  :  30).     A  better  method  is  to  remove  them  entirely  with 

4—2 


52 


DISEASES  OF  THE  PHARYNX  AND  LARYNX 


a  small  pair  of  Ruault's  or  Martin's  forceps,  and  then  to 
brush  over  the  surface  with  the  chloride  of  zinc  solution. 


Mycosis. 

Mycosis  occurs  as  white  clusters,  due  to  the  Leptothrix 
buccalis,  situate  on  the  surface  of  the  closed  follicles  of  the 
tonsils,  pharynx,  lingual  tonsils,  etc. 

Etiology. — Though  this  disease  occurs  fairly  frequently,  its 
pathology  is  still  obscure.  Commonl}/  met  with  in  adolescence 


Fig.  23. 


-Appearance  of  the  Tonsils  covered  with  Isolated 
Clumps  of  Mycosis. 


and  adult  life,  the  author  has  seen  it  in  young  children 
from  five  to  eight.  The  parasitic  elements  are,  however,  quite 
distinct  under  the  microscope  after  staining  with  a  solution 
of  tincture  of  iodine. 

Symptoms. — The  symptoms  are  variable.  Sometimes  they 
resemble  those  of  lacunar  tonsilhtis  ;  at  other  times  only 
a  roughness  in  the  throat  is  complained  of,  or  they  may  be 
almost  nil.  On  examination  of  the  throat  the  yellowish- white 
masses  arranged  in  clusters  are  seen  projecting  above  the 


PATHOLOGY  OF  THE  PHARYNX  S3 

subjacent  tissue  by  i  or  more  millimetres.  They  are  very 
adherent  to  the  mucosa,  which  is  neither  red  nor  inflamed, 
and  they  are  hard  to  the  touch.  Their  prominence  and  white- 
ness, with  the  irregular  and  fringed  border,  and  their  intimate 
connection  with  the  mucous  membrane,  enable  a  diagnosis 
to  be  made  from  the  caseous  secretions  or  diphtheroid 
exudates.  They  are  confluent  when  situated  on  the  tonsil, 
but  are  more  discrete  and  prominent  on  the  base  of  the 
tongue  and  on  the  pharynx.  In  this  disease  there  is  no 
sign  of  local  or  general  infection  ;  it  is  always  a  chronic 
condition,  and  may  last  for  months,  and  even  for  years,  if  left 
to  itself.  The  author  believes  that  the  persistence  of  mycosis 
is  due  to  the  growth  originating  at  the  bottom  of  the  crypts 
and  spreading  upwards  on  to  the  surface.  Unless  the 
forceps  entirely  remove  the  crypts  and  the  contained  growth, 
recurrence  takes  place. 

Treatment. — The  best  results  in  the  author's  experience  have 
been  obtained  by  epilation  with  the  forceps,  and  thereafter 
painting  over  the  surface — first  with  chloride  of  zinc  (i  :  15)  and 
then  with  an  iodated  solution  (i  :  5).  He  also  recommends  an 
iodated  gargle  daily,  which  facilitates  the  removal  of  those 
superficial  clusters  that  are  least  adherent.  Chromic  acid 
and  the  galvano-cautery  may  also  be  employed  if  the  growth 
be  very  persistent.  When  once  the  disease  is  eradicated,  it 
has  no  tendency  to  reappear. 

Foreign  Bodies  of  the  Tonsils — Calculus. 

The  tonsils,  from  their  position,  and  especially  on  account 
of  their  anfractuous  disposition,  frequently  become  the 
receptacle  for  foreign  bodies. 

Etiology. — Those  bodies  are  usually  of  a  sharp  nature,  fish- 
bones, pins,  etc.,  which  during  the  act  of  swallowing  become 
fixed  in  the  glands.  Sometimes  the  foreign  body  may  have  its 
origin  in  the  substance  of  the  tonsil  itself — e.g.,  a  tonsillar 
calculus,  which  occurs  in  subjects  who  have  hypertrophied 
glands  with  deep  crypts.  The  composition  of  a  tonsillar 
calculus  is  almost  the  same  as  that  of  the  analogous  salivary 


4'io 

grammes 

4*10  parts 

...     66-8o 

)  ) 

66-8o     „ 

...       4-15 

j> 

4'i5     „ 

...     16-95 

5  J 

16-95     ., 

870 

,, 

870     „ 

54  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

formation.     The   following  is  an  example  of  the  chemical 
analysis  of  a  tonsillar  calculus  : 

Calcium  carbonate 
Calcium  phosphate 
Magnesium  phosphate 
Organic  matter 
Water 

Symptoms. — The  existence  of  a  foreign  body,  especially  it 
it  be  of  a  sharp  nature,  is  usually  shown  by  more  or  less 
irritation  or  prickling  in  the  throat,  with  inconvenience  in 
swallowing.  On  the  other  hand,  in  the  case  of  a  calculus 
symptoms  may  be  almost  absent.  With  a  good  light 
the  foreign  body  may  be  frequently  recognized  on  direct 
examination.  In  the  case  of  very  small  fish-bones,  deeply 
sunk  in  the  substance  of  the  gland,  a  minute  examination  is 
sometimes  necessary,  before  their  presence  is  detected.  By 
the  aid  of  the  probe  or  curette  a  calculus  may  be  disclosed  by 
its  hardness  and  irregularity,  and  the  nature  of  the  foreign 
body  in  the  crypt  thus  explained. 

Diagnosis. — The  existence  of  pain  at  a  fixed  point  in  the 
throat  is  an  important  diagnostic  feature. 

Prognosis. — The  prognosis  is  usually  favourable.  It  should 
be  remembered,  however,  that  these  foreign  bodies  may  be 
the  starting-point  of  secondary  infections,  such  as  acute  or 
chronic  tonsillitis,  etc.,  and  which  might  not  be  successfully 
treated,  unless  the  cause  is  known  and  removed. 

Treatment. — This  consists  in  the  removal  of  the  foreign 
bodies  by  suitable  instruments.  In  the  case  of  a  calculus, 
the  crypt  in  which  it  is  situate  should  be  opened  with  the 
crotchet  or  curved  bistoury,  and  the  offending  mass  removed. 
Morcellement  is  also  adopted.  Ignipuncture  is  not  advisable, 
for  by  creating  cicatricial  synechiae  it  tends  to  the  formation 
of  new  calculus  growth. 

Tuberculous  Angina. 

A  localized  tuberculous  infection  of  the  pharynx,  either 
acute  (acute  miliary  tuberculosis)  or  chronic  (cedematous, 
hypertrophic,  lupoid,  or  latent  varieties). 


PATHOLOGY  OF  THE  PHARYNX 


5Ï 


Etiology. — The  invasion  of  the  pharynx  may  be  primary 
(lupoid  or  hypertrophic  forms)  or,  much  more  commonly, 
secondary,  due  to  pulmonary  disease.  With  the  exception 
of  the  lupoid  type,  it  is  very  unusual  to  have  a  tuberculous 
pharynx  without  disease  in  the  larynx  or  lungs.  The  disease 
is  more  frequently  seen  in  adults  than  in  the  young  or  in  the 
aged,  and  in  males  more  than  in  females. 


I.  Acute  Miliary  Tuberculosis. 

Symptoms. — The  most  marked  symptom  is  pain,  which  is 
always  considerable,  shooting  up  to  the  ears,  and  specially 
marked  in  deglutition.     Liquids,  such  as  the  saliva,  milk,  or 


Fig.  24. — Acute  Miliary  Tuberculosis. 

soup,  are  swallowed  with  difficulty.  Regurgitation  of  fluids 
through  the  nose  occasionally  takes  place  through  inaction 
of  the  soft  palate  from  infiltration.  For  the  same  reason  the 
voice  becomes  altered  in  tone.  The  expectoration  of  muco- 
purulent secretions  which  accumulate  in  the  throat  is  difficult, 
on  account  of  the  extreme  pain  and  the  palatal  condition. 
The  adenopathy  noted  by  some  authors  rarely  exists,  and 


56 


DISEASES  OF  THE  PHARYNX  AND  LARYNX 


is  only  of  secondary  importance.  The  glands  are  usually 
movable,  indurated,  and  are  not  at  all  or  only  slightly 
painful. 

Acute  miliary  angina  shows  itself  in  two  forms,  ulcerative 
and  vegetative,  which  are  sometimes  combined. 

(a)  Ulcerative  Form. — The  mucosa  is  altered  to  a  dull 
grey  colour,  with  a  pale  miliary  infiltration  of  its  substance 
superficially  placed.     This  breaks  down  into  little  cup- shaped 


Fig.  25. — Tuberculous  Angina  (Œdematous  Sclerotic  Form). 


erosions,  surrounded  by  soft  or  even  œdematous  tissue. 
These  coalesce  and  form  ulcers.  The  base  is  greyish  and 
the  edges  are  undefined.  On  the  edge  of  the  principal  ulcer 
are  small  greyish-yellow  miliary  tubercles,  which  diminish 
as  they  pass  outwards  into  the  healthy  parts.  The  ulcers 
are  anfractuous,  with  irregular  infiltrated  edges  festooned  on 
the  pillars.  They  are  multiple,  and  are  situated  generally 
on  the  pillars,  base  of  tongue,  and  tonsils  (buccal  or  lingual). 
These  may  unite  with  similar  ulcers  situated  on  the  epiglottis 


PATHOLOGY  OF  THE  PHARYNX  57 

or  soft  palate.  The  part  most  rarely  affected  is  generally  the 
mesial  pharyngeal  wall.  The  lesion  does  not  appear  to 
spread  beyond  the  level  of  the  insertion  of  the  posterior 
pillars.  Salivation  is  abundant,  both  from  the  local  lesion 
and  from  the  dysphagia. 

{b)  Vegetative  Form. — This  is  a  slower  form,  almost 
chronic  in  its  course.  Functional  symptoms  are  slightly 
marked,  except  pain,  which  is  sufficient  to  call  the  attention 
of  the  patient  to  his  throat. 

The  tissues  appear  shagreened,  and  covered  over  by  a 
broad  superficial  erosion  which  gradually  deepens,  leaving  a 
vegetative,  even  polypiform,  surface,  showing  the  appearance 
of  a  hypertrophic  rather  than  a  destructive  lesion.  The 
edges  are  ill-defined,  fading  away  into  the  surrounding  tissue, 
where  small  yellowish-grey  miliary  tubercles  are  seen  scat- 
tered over  the  pale  and  discoloured  mucous  membrane. 

These  two  forms  of  miliary  angina  are  nearly  always 
accompanied,  or  rather  preceded,  by  bacillary  laryngitis, 
and  habitually  with  pulmonary  phthisis. 

The  vegetative  form  would  appear  to  be  intermediate 
between  acute  ulcerous  tuberculosis  and  the  lupoid  variety. 

2.  Chronic  Forms. 

(a)  The  Infiltrated  Œdematous Type. — Thisisasub- 
acute  or  chronic  angina,  in  which  infiltration,  or  sclerema, 
occurs  in  the  tissues  of  the  uvula,  soft  palate,  epiglottis,  and 
sometimes  the  posterior  pharyngeal  wall,  and  almost  always 
the  epiglottis.  The  affected  tissue  is  of  a  pale  yellowish- 
grey  colour,  and  hard  to  the  touch.  The  uvula  may  feel  to 
the  finger  like  fibro-cartilage. 

The  author  has  seen  this  form  of  tuberculosis  of  the  throat 
advance  very  slowly  for  several  years,  and  even  cure  result- 
ing if  the  treatment  was  regularly  carried  out.  As  a  rule, 
however,  we  see,  especially  in  the  spring  and  autumn,  the 
development  of  small  acute  inflammatory  growths  on  this 
mucosa.  This  becomes  covered  over  here  and  there  by 
small  superficial  erosions,  which  are  sufficiently  painful  to 
inconvenience  deglutition,  especially  when  they  are  on  the 


58  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

epiglottis  or  base  of  the  tongue.  According  as  these  growths 
recur,  more  or  less  often,  we  divide  these  cases  into  the  sub- 
acute or  the  chronic. 

Symptoms. — Nasal  speech  from  the  stiffness  or  immobility 
of  the  soft  palate.  It  is  rare  to  have  regurgitation  of  liquids 
through  the  nose,  because  the  infiltration  of  this  organ  prob- 
ably protects  the  naso-pharynx  against  the  penetration  of 
food.  There  is  no  pain,  or  it  is  only  observed  on  the  occur- 
rence of  the  acute  attacks  already  referred  to,  and  specially 
during  deglutition.  The  general  condition  is  so  well  main- 
tained, that  one  would  suspect  that  this  angina  is  due  to  some 
other  cause  than  bacillary  disease.  In  cases  which  are  doubt- 
ful one  should  remove  a  portion  of  the  tissue  for  examination. 

(b)  Lupus — Symptoms. — Lupus  of  the  pharynx  is  far  from 
being  a  rare  condition.  Sometimes  primary,  it  is  much  more 
often  secondary  to  analogous  lesions  of  the  skin,  nasal  fossae^ 
larynx,  or  gums.  Lupus  may  follow  a  purulent  pseudo- 
atrophic  coryza — a  true  bacillary  catarrh — in  which  there 
is  no  erosion  or  ulceration.  From  the  researches  of 
MM.  Dubreuille,  Meneau,  and  Frèche,  we  know  that  lupus 
of  the  skin  is  in  most  cases  secondary  to  an  identical  affec- 
tion in  the  nose.  However,  certain  kinds  of  lupus  of  the 
skin  are  not  accompanied  by  characteristic  clinical  signs  of 
disease  in  the  nasal  fossa.  On  the  other  hand,  a  kind  of 
pseudo-atrophic  coryza  with  yellow  crusts,  without  odour 
and  with  a  purulent  or  muco-purulent  secretion,  is  nearly 
always  observed  among  cutaneous  lupous  patients.  This  the 
author  is  disposed  to  consider  as  a  kind  of  prelupoid 
bacillary  catarrh,  susceptible  of  favouring  the  development 
of  lupus,  not  only  on  the  skin,  but  also  on  the  pharyngeal 
mucosa.  This  hypothesis  is  still  very  difficult  to  verify, 
seeing  that  with  the  methods  of  examination,  bacteriological 
and  otherwise,  at  our  disposal,  we  have  been  unable  to  de- 
monstrate in  a  positive  manner  the  existence  of  bacilli.  The 
inoculations  have  nearly  all  been  negative  ;  nor  is  that  to  be 
wondered  at,  seeing  that  even  in  lupous  tissue  it  is  not  always 
possible  to  obtain  conclusive  inoculations,  any  more  than  it 
is  easy  to  get  Koch's  bacillus  in  cut  sections  of  this  patho- 


PATHOLOGY  OF  THE  PHARYNX  59 

logical  tissue.  It  is  not  exceptional  to  see  lupus  of  the 
throat  alone.  Pain  is  almost  awanting  ;  there  is  scarcely 
any  inconvenience  experienced  in  deglutition,  whether  of 
saliva  or  of  irritating  foods.  There  is  sometimes,  however, 
a  little  burning  sensation,  with  slight  dysphagia,  and  this 
is  usually  associated  with  the  formation  of  acute  growths 
Frequently,  then,  in  spite  of  a  very  pronounced  local  lesion, 
the  general  symptoms  are  absolutely  awanting,  as  well  as  the 
evidence  of  pulmonic  disease. 

Lupus  attacks  by  preference  the  lateral  parts  of  the  throat, 
the  pillars,  soft  palate,  tonsils,  and  base  of  the  tongue.  The 
general  colour  of  the  mucosa  is  not  altered.  At  the  begin- 
ning of  the  process  small  reddish  granulations  are  seen  to 
be  studded  over  an  infiltrated,  softened,  and  rosy-coloured 
mucous  membrane.  It  is  sometimes  almost  impossible  to 
distinguish  even  under  good  light  and  careful  examination 
where  the  healthy  and  the  diseased  tissues  meet.  These  reddish 
excrescences  diminish  in  size  as  they  spread  outwards  to  the 
healthy  tissue.  There  is  frequently  ulceration  in  the  centre 
of  the  patch,  covered  over  with  a  greyish  secretion.  When 
the  pillars  are  involved  they  present  a  mammillated  appear- 
ance, resembling  a  mulberry.  This  is  a  pseudo-hypertrophic 
tuberculosis.  By  curetting  it  is  easy  to  see  how  much  these 
apparently  superficial  lesions  are,  on  the  contrary,  deep  and 
destructive.  As  the  disease  progresses,  whitish  cicatricial 
bands  are  observed,  stretching  from  above  downwards,  either 
on  the  pharyngeal  wall,  which  they  furrow,  or  on  the  pos- 
terior pillars.  Those  dull  yellowish  or  greyish  cicatrices 
are  covered  over  from  time  to  time  with  small,  irregular 
ulcers,  which  are  somewhat  painful.  It  may  invade  also  the 
base  of  the  tongue,  the  palatal  vault,  the  epiglottis,  and  even 
the  whole  larynx.  Those  inflammatory  symptoms  are  more 
common  in  spring  and  autumn,  and  have  been  seen  to  appear 
regularly  during  several  consecutive  years.  They  leave  be- 
hind pale  nodular  scars. 

(c)  Hypertrophic  Form. — The  author  would  designate 
this  the  pseudo  -  hypertrophic  tonsillar  variety,  to  which 
Professor    Dieulafoy  has    recently  called    attention.     There 


6o  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

are  no  local  functional  symptoms,  and  it  would  appear  as 
if  we  were  dealing  with  a  simple  tonsillar  hypertrophy,  until 
a  histological  examination  is  made,  when  the  presence  of 
caseous  nuclei,  giant  cells,  and  Koch's  bacillus  is  demonstrated. 
It  usually  shows  itself  in  children  of  healthy  appearance 
and  of  good  history.  The  researches  of  Dr.  Bruedel  show 
that  these  patients  are  in  no  way  more  predisposed  than 
others  to  remote  tuberculosis,  as  the  nucleus  of  concealed 
tuberculosis  is  surrounded  by  a  zone  of  sclerosis  and  becomes 
healed. 

Course. — In  acute  miliary  tuberculosis  the  course  is  usually 
rapid,  and  generally  occurs  in  the  last  stage  of  the  tubercular 
affection,  precipitating  the  fatal  event. 

The  vegetative  form  is  subacute  in  its  course. 

The  chronic  œdematous  form  and  the  lupoid  are  much 
slower,  and  advance  by  a  series  of  successive  exacerbations. 

With  well-directed  treatment,  local  and  general,  healing 
can  be  obtained,  at  least  for  a  time,  leaving  behind  it  a 
series  of  fibrous  cicatrices,  which  are  so  extensive  as  to  cause 
contraction  of  the  naso-pharyngeal  orifice. 

In  the  hypertrophic  form  we  are  unable  to  say  anything 
regarding  its  progress  or  duration,  since  it  is  often  only 
recognized  from  the  histological  examination  of  a  tonsil, 
which  has  been  removed  on  account  of  its  hypertrophy.  It 
can  be  understood  that,  if  left  alone  in  young  children,  it  may 
be  the  starting-point  of  local  infection,  which  may  become 
general. 

Prognosis. — This  depends  on  the  degree  of  the  general 
infection  of  the  individual,  and  on  the  form  and  progress 
of  the  disease.  The  pathology  varies  in  no  wise  from  the 
disease  elsewhere,  except  in  the  fact  that  Koch's  bacilli, 
which  are  easily  demonstrated  in  the  acute  forms,  are  excep- 
tionally rare  in  the  chronic  forms. 

Diagnosis. — Acute  miliary  tuberculosis  cannot  be  mistaken 
for  any  other  ulcerous  condition.  Indeed,  the  coexistence 
of  pulmonary  and  laryngeal  lesions,  the  functional  disturb- 
ances, the  appearance  of  the  lesions  and  of  the  patient, 
generally   suffice   to    make   a   diagnosis.     Thrush,    aphthae, 


PATHOLOGY  OF  THE  PHARYNX  6i 

angina  with  the  development  of  a  false  membrane,  are  all 
distinguished  from  it  by  their  general  symptoms,  and  specially 
by  their  course  and  duration. 

Lupus  has  to  be  differentiated  from  syphilitic  ulceration, 
which  bears  some  resemblance  to  it.  The  coexistence  of 
cutaneous,  nasal,  or  analogous  buccal  lesions  is  important 
in  establishing  a  diagnosis.  Lupus  is  essentially  chronic, 
while  syphilis  shows  itself,  on  the  contrary,  to  be  a  rapidly 
destructive  lesion.  Syphilis  attacks  by  preference  the 
pharyngeal  wall,  lupus  the  lateral  walls.  The  syphilitic 
ulcer  is  cup-shaped,  with  projecting,  punched-out  edges, 
which  are  red,  anfractuous,  and  clearly  differentiated  from 
the  surrounding  tissues.  The  base  of  the  ulcer  is  greyish, 
suppurative,  serpiginous  in  form.  In  lupus,  on  the  other 
hand,  the  edges  are  badly  defined,  the  ulcer  more  superficial, 
and  covered  over  with  pinkish  granulations.  They  are 
multiple,  sometimes  separated  from  each  other  by  healthy 
tissue.  They  are  not  very  painful  and  are  more  diffused. 
Pain,  which  is  almost  absent  in  lupus,  is,  as  a  rule,  more 
marked  in  syphilitic  cases.  Specific  treatment  soon  clears 
up  the  doubtful  diagnosis. 

When  lupus  is  grafted  on  a  syphilitic  patient,  then  there 
is  great  difiiculty  of  diagnosis.  Reliance  must  not  be  placed 
on  the  positive  or  negative  evidence  of  the  history.  In  many 
cases  the  patients  will  not  own  to  having  had  syphilis,  and 
if  they  do,  the  practitioner  is  inclined  to  mark  the  lesion 
syphilitic,  even  though  it  is  a  case  of  a  clearly  tuberculo- 
lupus  nature.  Again,  the  patient  may  not  know  his  ante- 
cedent history — e.g.,  in  a  hereditary  case. 

With  regard  to  the  ulcerative  processes  in  the  eruptive 
fevers,  the  coexistence  or  the  pre-existence  of  pyrexia  would 
suggest  the  diagnosis. 

Finally,  in  cancer  of  the  pharynx  we  have  a  true  vegetative 
growth,  with  indurated  edges  causing  immobility  of  the 
affected  tissue,  followed  by  the  characteristic  glandular 
involvement,  with  fetor  of  the  breath. 

In  a  doubtful  or  difficult  case  the  progress  of  the  disease 
will  determine  the  real  nature  of  the  morbid  process. 


62  DISEASES  OF  THE  PHARYXX  AXD  LARYXX 

Treatment. — In  the  acute  miliar}-  form  treatment  should 
be  confined  to  assuaging  the  painful  dysphagia,  -vvhich  is  the 
predominant  symptomi  of  the  disease.  In  such  a  case  the 
methods  at  our  disposal  unfortunately  fail,  neither  morphia, 
cocaine,  nor  orthoform  relieving  the  intolerable  pain.  Frequent 
washings  of  the  pharynx  with  alkaline  solutions  are  useful 
(borate  or  benzoate  of  soda,  antipvrin,  etd. 


1^  Benzoate  of  soda 

8  grammes 

oil 

Resorcin 

...       6        „ 

ôiss 

Antipvrin 

4 

51 

Glycerine 

...   250 

5vii 

A   teaspoonful    in    half   a    gla 

ss   of  tepid   or   sli 

ghtly 

warm 

water. 

li  Carbolic  acid 

60  centigrammes 

gr.  9 

Hydrochloride  of  morphine 

25  to  50 

gr 

.  4  to  8 

Hydrochloride  of  cocame 

50  centigrammes 
to  I  gramme 

gr. 

S  to  16 

Menthol 

I  gramme 

gr-i5 

Glycerine 

50  grammes 

ôxi 

Distilled  water 

45^ 

gxvi 

Dissolve  the  menthol  in  a  little  alcohol  and  filter  the  solution, 
to  remove  the  excess  of  menthol,  which  will  not  dissolve. 

The  following  may  be  used  if  the  pain  is  less  excessive  : 

I^  Antipyrin  "1 

Bromide  of  sodium-' 

Hydrochloride  of  cocaine     . . . 

Gl3-cerine 

Spirit  of  peppermmt  -  '  alcool 

de  menthe  ' ] 
Water      ... 

This  should  be  used  as  a  spray  three  or  f  jur  times  a  day  when 
food  is  taken.  The  patient  should  rinse  his  mouth  with  an 
alkaline  lotion  to  prevent  any  of  the  anéesthetic  fluid  getting 
into  the  stomach  and  spoiling  an  already  indifferent  appetite. 


aa  5  grammes 

(gr.  78 
lgr.78 

50  centigrammes 

gr.8 

50  grammes 

.-jxi 

5         J' 

iil_lxxx 

45''-^ 

5xvi 

PATHOLOGY  OF  THE  PHARYNX  63 

Painting  the  throat  with  the  following  formula  is  useful  : 

^  Biborate  of  soda  ...  . .  3  grammes  gr,  45 

Hydrochlordie  of  cocaine  ...  i  gramme  gr.  15 

Cherry-laurel  water"^  __  i     3iv 

^,        •'.  -  ...      aa  15  grammes  -:  _... 

Glycerme  J  ^  [  .^iiiss 

A  solution  of  menthol  in  oil  (i  :  10),  as  recommended  by 
Rosenberg,  has  sometimes  a  sedative  effect.  A  spray  of 
iodoform  in  ether  is  very  useful. 

After  curetting  the  ulcerated  surface  the  following  insuffla- 
tion will  be  found  very  helpful  : 

B:  Orthoform     1  __  fgr.  78 

-r^.  .    -,   r-  ■■•  •••     aa  5  grammes  -^     \ 

Di-iodoformJ  tgr.  78 

Menthol  ...  ...  ...  i  gramme  gr.  15 

Or  still  better  : 

li   Hydrochloride  of  cocaine         60  centigrammes   gr.  gtoi5 

to  I  gramme 

Hydrochloride  of  morphine      10  centigrammes  gr.  i| 

Menthol  ...  ...  i  gramme  gr- 15 

Iodoform  (powder)   ■)  __  „  (3ii 

.  )  -    ...       aa  8  grammes 

Boric  acid  (powder)  J  (on 

A  pinch  to  be  insufflated  once  or  twice  a  day  into  the  back 
of  the  throat. 

Such  are  the  formula  which  will  help  to  ameliorate  the 
painful  symptoms  and  assist  in  healing  the  ulcers.  If  a 
favourable  result  is  obtained,  a  slight  curetting  of  the 
ulcerated  surface  may  be  practised  from  time  to  time  with 
carbolized  glycerine  (from  i  :  10  to  i  :  3),  or  with  lactic  acid, 
which  is  so  highly  recommended  in  tuberculous  laryngeal 
cases  by  Krause  and  Hering. 

In  the  lupoid  or  subacute  forms  we  can  only  say,  that 
if  the  treatment  is  well  carried  out,  a  successful  issue  is 
almost  certain.  As  soon  as  diagnosis  is  made,  it  is  well  to 
scrape  away  energetically  all  the  diseased  tissue,  in  order 
to  suppress  the  softer  vegetating  granulations.    The  bleeding 


64 


DISEASES  OF  THE  PHARYNX  AND  LARYNX 


surface  is  then  cauterized  by  a  solution  of  lactic  acid  (i  :  3), 
or  even  the  pure  acid,  by  glycerine  and  carbolic,  or  by  the 
galvano-cautery  lightly  applied.  This  in  the  form  of  igni- 
puncture  is  an  excellent  way  of  obtaining  a  cicatricial 
sclerosis. 

After  cure  the  patient  should  be  watched,  for  relapses  may 
occur. 

The  local  treatment  of  tuberculous  infiltrating  œdematous 
angina  should  consist  of  emollient  or  slightly  astringent 
gargles  during  the  sharp  onsets.  During  the  chronic  sclere- 
matous  stage  the  author  prefers  ignipuncture  applied  to  the 
substance  of  the  tissue  every  fifteen  or  twenty  days.  The 
fine  galvanic  point  should  be  inserted  from  i  to  i  J  centimetres, 
and  thus  form  cicatricial  tissue.    By  this  treatment,  to  which 


Fig.  26. — Various  Cautery  Points. 


may  be  sometimes  added  resection  of  the  infiltrated  portions, 
the  author  has  seen  the  lesion  diminish  gradually.  The 
patients  ought  in  such  cases  to  be  kept  under  observation 
for  years,  for  fear  of  bacillary  infection. 

The  general  treatment  in  acute  cases  is  the  air  cure,  rest, 
and  superabundance  of  food. 

In  lupoid  or  subacute  forms  general  tonics  should  be  given, 
especially  iodine  and  cod-liver  oil  if  it  can  be  borne.  Lupus, 
once  cured,  leaves  whitish  scars  ;  it  sometimes  produces  con- 
strictions of  the  naso-pharynx,  which  may  be  so  great  as  to 
occlude  the  naso-pharynx  from  the  pharyngeal  cavity.  This 
is  of  very  rare  occurrence. 

In  hybrid  tuberculous  and  syphilitic  cases  the  specific 
treatment  should  be  employed  with  care. 


PATHOLOGY  OF  THE  PHARYNX  65 

Syphilis  of  the  Pharyngeal  Cavity, 

Under  the  term  syphilis  of  the  pharyngeal  cavity  may  be 
included  the  lesions  produced  by  syphilis  during  the  primarj', 
secondary,  and  tertiary  stages,  on  the  mucous  membrane  of 
the  pharynx. 

I.  Chancre. 

This  is  usually  situate  on  the  tonsil.  The  lesion  perhaps 
occurs  more  frequently  than  was  formerly  supposed,  and  is 
commonly  the  result  of  direct  inoculation,  as  from  the  nipples 
of  the  nurse,  infected  utensils,  and  unnatural  offences.  The 
presence  of  acute  inflammation  of  the  tonsil  predisposes  to 
infection. 

The  chancre  may  assume  the  anginous,  erosive,  or  ulcerous 
types.  These  all  present  common  characteristics,  such  as 
great  swelling  of  the  infected  gland,  which  may  be  three  or 
four  times  its  ordinary  size,  stretching  into  the  middle  line 
close  to  the  uvula.  The  tonsil  presents  a  reddish  appearance, 
hard  to  the  touch  but  painless.  The  lymphatic  chain  is 
enlarged  at  the  angle  of  the  jaw,  one  gland  being  more  so 
than  the  others.  It  is  unilateral.  These  glands  are  painless, 
movable,  hard,  and  numerous,  and  that  they  are  swollen  may 
be  perceptible  to  the  eye.  The  skin  covering  them  is  normal 
in  colour  and  movable. 

In  the  anginous  form  the  chancre  may  begin,  like  ordinary 
tonsillitis,  with  a  pultaceous  exudation.  This  may  not  at  first 
be  suspected  as  a  case  of  syphilitic  angina  till  certain  factors 
are  taken  into  account,  such  as  the  long  duration  of  the  angina, 
its  unilateral  nature,  with  the  characteristic  adenopathy. 

In  the  erosive  form,  in  addition  to  the  above  symptoms, 
we  see  a  small  membranous  diphtheroid  exudation  on  the 
tonsil,  and  showing  beneath,  on  removal,  fungoid  ulceration, 
which  is  replaced  afterwards  by  a  mucous  patch. 

Finally,  in  other  cases  we  see  on  the  tonsil  a  true 
crateriform  ulceration.  The  base  is  grey,  pultaceous  in 
appearance,  and  the  edges  are  hard,  red,  and  irregular. 
At  first  sight  this   might    be    mistaken    for  an  epithelioma, 

5 


66  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

or  even  a  gumma,  but  for  the  course  of  the  disease — 
the  speciâ.1  glandular  involvement  and  the  fades  of  the 
patient. 

2.  Secondary  Stage. 

Erythema. — This  appears  to  consist  simply  in  a  diffused 
redness  over  the  entire  mucosa.  The  hypergemia  is  more 
marked  over  the  soft  palate,  pillars,  and  tonsils,  which  latter 
are  usually  slightly  enlarged.  Punctuated  red  spots,  like 
those  seen  in  scarlet  fever,  appear,  but  are  much  more  dis- 
crete and  without  the  general  phenomena. 

Hypertrophy. — ^The  tonsils  are  generally  bilaterally 
affected,  and  can  only  be  distinguished  from  simple  hyper- 
trophy by  their  more  congested  appearance,  by  the  con- 
comitant erythema  of  the  soft  palate  and  pillars,  and  by 
the  rapid  evolution  of  its  progress.  This  hypertrophy 
occurs  also  in  the  other  masses  of  lymphoid  tissue  in  the 
neighbourhood,  and  is  so  frequently  seen  that  it  deserves  the 
special  attention  of  the  clinician.  The  following  symptoms 
should  help  in  making  a  diagnosis  :  The  presence  of  diffused 
hypertrophy  rapidly  taking  place  in  an  individual,  who  had 
previously  no  such  enlargement  ;  the  characteristic  tonsillar 
voice,  this  occurring  without  inflammatory  reaction  ;  rapid 
hypertrophy,  accompanied  by  submaxillary  adenopathy,  and 
the  duration  prolonged  beyond  the  ordinary  limits  of  an 
inflammatory  tonsillitis. 

The  development  of  other  symptoms,  such  as  roseola, 
nocturnal  headache,  falling  out  of  the  hair,  etc.,  should  clear 
up  the  diagnosis. 

Mucous  Patches. ^The  throat  is  the  favourite  situation 
of  the  mucous  patch  in  various  forms  :  the  erosive,  the 
papulo-eruptive,  the  papulo-hypertrophic  or  the  ulcerous. 
The  erosive  and  the  papulo-erosive  are  the  most  commonly 
seen.  Greyish  in  colour,  they  project  above  the  mucous 
membrane,  and  are  very  similar  in  appearance  to  the  stain 
caused  by  the  nitrate  of  silver  pencil.  They  are  localized 
usually  over  the  anterior  pillars,  the  soft  palate,  the  tonsils, 
and    sometimes    over   the    posterior   pillars.     They   do    not 


PATHOLOGY  OF  THE  PHARYNX 


67 


occur  on  the  pharyngeal  wall  proper.  They  are  not  in- 
frequently observed  on  the  lingual  tonsil.  Their  form  is 
very  variable — sometimes  round  or  elongated  ;  at  other  times 
they  are  almost  confluent,  with  irregular  margins.  The 
edges  are  red  and  sharply  defined.  In  very  slight  cases 
there  is  frequently  found  on  the  clear  border  of  the  anterior 
pillar  a  small  greyish  streak  with  a  carmine-coloured  border, 
usually  bilateral,  though  sometimes  more  pronounced  on  the 
one  side  than  the  other.     The   persistent    duration    of  the 


Fig.  27. — Mucous  Patches  of  the  Palate,  Anterior  Pillars, 
AND  Tonsils. 


lesion  in  this  locality  should  suggest  the  possibility  of 
syphilis,  and  the  necessity  of  looking  out  for  other  signs  to 
strengthen  the  diagnosis. 

The  secondar}^  angina  may  commence  like  an  acute  angina, 
and  is  known  as  the  diphtheroid  form.  In  these  cases  the 
tonsils  and  pillars  are  covered  over  at  first  with  small  whitish 
patches,  which  disappear,  but  the  angina  remains  beyond 
the  limit  of  an  acute  condition.  On  careful  examination, 
mucous    patches    are    frequently  found  scattered    over   the 

5—2 


68  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

mucosa  of  the  cheek,  Hps,  lingual  tonsil,  etc.  The  roseolar 
cutaneous  rash  usually  follows  very  soon  after  this  lesion. 

The  ulcerous  form  is  very  frequently  seen  among  smokers. 
In  the  same  way  the  papulo-hypertrophic  patches — true 
condylomata — are  observed  in  subjects  who  have  been  deeply 
infected,  but  whose  treatment,  through  negligence  or  errors 
of  diagnosis,  has  been  delayed.  The  author  has  seen  them 
invade  all  the  pharynx,  extending  to  the  bony  palate,  and 
resembling  the  analogous  lesions  seen  on  the  genital  mucosa. 

The  symptoms  are,  as  a  rule,  not  well  marked.  Some 
inconvenience  in  swallowing  may  be  complained  of  and 
cause  the  sufferer  to  seek  advice. 

In  some  of  the  diffuse  ulcerous  forms  pain  may  be  present, 
even  shooting  up  to  the  ears  during  deglutition.  The 
secondary  symptoms  may  last  for  some  months,  and  may 
even  recur  during  the  first  or  second  year.  Those  persistent 
cases  are  usually  seen  in  smokers,  and  the  lesion  may  not 
heal  unless  the  habit  is  given  up. 

As  regards  the  long  duration  of  a  syphilitic  angina, 
Dr.  Garel  of  Lyons  states  that  any  angina  which  is  pro- 
longed beyond  twelve  or  fifteen  days  should  be  considered 
suspicious. 

3.  Tertiary  Stage. 

Before  the  development  of  this  stage  there  is  a  form  of 
secundo-tertiary  ulceration  which  succeeds  the  mucous 
patches.  These  lesions  are  deeper  than  those  of  the 
secondary  period,  and  are  localized  usually  on  the  edge  of 
the  uvula  and  anterior  pillar.  They  are  met  with  in 
smokers,  in  the  non-treated  cases,  and  where  the  infection 
has  been  severe. 

It  is  usual  to  distinguish  two  kinds  of  tertiary  lesions  in 
the  throat — the  gummatous  and  the  ulcerative.  The  author 
thinks,  however,  it  is  more  logical  to  consider  the  ulceration 
as  a  result  of  the  gumma.  It  is  rare  to  see  a  patient  in  the 
gummatous  stage,  as  it  is  nearly  always  during  the  period  of 
ulceration  that  advice  is  sought. 

The  gumma  has  a  reddish   smooth  surface,  more  or  less 


PATHOLOGY  OF  THE  PHARYNX  69 

localized,  and  is  hard  to  the  touch.  After  a  certain 
period  it  begins  to  soften,  when  little  crater-like  excava- 
tions are  formed,  with  distinct  anfractuous  punched-out 
borders.  These  tertiary  ulcers  are  situate  on  the  posterior 
and  lateral  wall  of  the  pharynx,  are  serpiginous  in  form, 
and  extend  from  the  naso-pharynx  to  the  entrance  of  the 
oesophagus.  They  also  occur  on  the  soft  palate  (on  both 
the  anterior  and  posterior  surface),  the  posterior  pillars,  and 
at  the  lower  border  of  the  tonsil  at  its  junction  with  the 
tongue.     The  loss  of  tissue  may  be  very  great,  the  larger 


Fig.  28. — Tertiary  Syphilis  of  the  Pharyngeal  Cavity  and  of 
THE  Pharynx. 

part  of  the  pharynx  being  transformed  into  one  large 
excavation,  with  a  grey  sloughy  base.  It  looks  as  if  the 
tissue  had  been  punched  out.  When  the  soft  palate  is 
attacked,  great  destruction  often  results.  The  tissues  are 
very  red,  infiltrated,  and  well  defined.  At  the  junction  of 
the  hard  and  soft  palate,  a  broken-down  gumma,  which  has 
penetrated  through  the  osseous  tissue  into  the  nose,  is 
frequently  seen.  These  osseous  gummata  are  also  very 
common  in  the  mesial  line  and  behind  the  dental  arch. 
They  may  occur  on  the  pharyngeal  wall,  sometimes  causing 
necrosis,  when  death  may  suddenly  result  from  haemorrhage. 


/O 


DISEASES  OF  THE  PHARYNX  AND  LARYNX 


Diagnosis. — The  diagnosis  of  a  tonsillar  chancre  may  be 
somewhat  difficult,  since  it  may  commence  like  an  acute 
angina.  It  is  especially  from  the  characteristic  glandular 
involvement,  the  general  infection  of  the  subject,  the  progress 
of  the  disease,  and  particularly  the  early  appearance  of  other 
secondary  symptoms,  that  diagnosis  may  be  determined. 
However,  in  doubtful  cases  the  long  duration  of  the  lesion, 
and,  speaking  generally,  its  slow  and  comparatively  painless 
progress,  should  arouse  suspicion. 


--^ 

Fig.  29. — Tertiary  Syphilis  of  the  Pharyngeal  Cavity. 

The  secondary  symptoms  are  distinguished  by  their  appear- 
ance, and  by  the  persistence  of  the  angina  beyond  the  usual 
time. 

Reference  has  already  been  made  to  the  gumma  in  con- 
nection with  tuberculosis. 

Course. — The  chancre  usually  heals  without  any  treatment. 
The  secondary,  no  doubt,  may  also  disappear  ;  but  if  speclhc 
treatment  is  not  adopted  to  check  its  progress,  the  patient 
may  be  caused  considerable  inconvenience.  Slight  secondary 
symptoms  appearing  in  a  subject  who  is  careful  in  his  personal 


PATHOLOGY  OF  THE  PHARYNX  71 

habits  unfortunately  disappear  without  being  treated,  leaving 
the  patient  exposed  to  the  tertiary  lesions  ;  for  cases  where 
early  treatment  has  been  omitted  are  those  affected  w4th 
gummata  and  their  sequelae. 

Tertiary  lesions,  on  the  other  hand,  if  left  to  themselves, 
have  no  tendency  to  heal,  and  they  produce  great  destruction, 
as  we  have  seen.  When  once  a  bony  tissue  is  necrosed, 
specific  treatment  fails.  The  peripheral  parts  of  the  mucosa 
heal  under  treatment,  but  until  the  sequestrum  is  removed 
cicatrization  will  not  take  place.  Cicatricial  tissue  may  be 
very  pronounced — so  much,  indeed,  that  extensive  strictures, 
either  in  the  naso-pharynx  or  at  the  laryngeal  entrance,  take 
place. 

Treatment  is  the  same  in  all  stages — the  exhibition  of 
specifics.  For  his  part,  when  he  wishes  to  heal  any  of  the 
lesions,  even  in  the  secondary  stage,  the  author  does  not 
hesitate  to  give  the  biniodide,  as  in  the  following  : 

R  Biniodide  of  mercury    15  to  20  centigrammes      gr.  25- to  3 
Iodide  of  potassium     15  to  20  grammes  3ivto  v 

Water    ...  ...     300  grammes  5X 

A  tablespoonful  morning  and  evening  in  a  little  water  at 

meals. 

It  has  very  seldom  been  necessary,  even  in  the  case  of 
very  pronounced  lesions,  to  exceed  20  grammes  of  iodide  of 
potassium,  if  the  treatment  was  regularly  carried  out. 

Even  in  very  grave  forms  of  syphilis  the  author  has  noticed 
that  in  forty-eight  hours  or  three  days  the  patient  ex- 
perienced considerable  relief,  which  could  not  always  be 
explained  by  examination,  and  after  a  week  to  ten  days  the 
improvement  could  be  readily  seen. 

When  the  lesions  have  disappeared  or  diminished,  but  are 
still  in  the  secondary  stage,  he  prescribes  the  following  pills  : 

R  Protoiodide  of  mercury         25  milligrammes  gr.  f 

Extract  of  opium  ...        i  centigramme  gr.  i 

Extract  of  cinchona       ...       2  centigrammes  •  gr.  ^ 

Two  to  three,  or  even  four,  pills  to  be  taken  daily,  one  or 


72  DISEASES  OF  THE  PHARYNX  AXD  LARYNX 

two  compressed  chlorate  of  potash  lozenges  being  allowed 
to  melt  in  the  mouth  at  the  same  time. 

This  treatment  is  to  be  continued,  with  intervals  of  rest, 
according  to  the  toleration  and  degree  of  infection  of  each 
patient.  Mercury  ma^'  be  given  with  care  subcutaneously. 
It  is  indicated  in  cases  where  the  digestive  tract  is  trouble- 
some. In  the  tertiary  stage  the  author  prefers  to  use  the 
mixed  treatment,  as  it  gives  better  results. 

Locally, — In  the  second^stage,  undoubtedly  the  best  treat- 
ment is  to  paint  the  ulcerated  part  with  a  strong  solution  of 
iodine  (i  :  3  or  i  :  5),  twice  a  week.  If  the  lesions  are  obstinate 
and  very  diffused  he  uses  a  solution  of  nitrate  of  mercury  (1:5). 
With  the  latter  the  painting  should  only  take  place  once 
every  eight  or  ten  days.  In  addition,  an  iodine  gargle  is 
given,  as  follows  : 

B:  Iodine  ...  ...        30  centigrammes         gr.  5 

Iodide  of  potassium  ...        50  ,,  gr.  7^ 

Laudanum  (Sydenham's)  ...  3  grammes  TIl^xlv 

Pure  glycerine      ...  ...      150  ,,  §iv 

A  teaspoonful  to  a  half  or  whole  glass  of  tepid  water  used 

as  a  gargle  after  each  meal. 

In  the  treatment  of  tertiar}'  ulcers  cleanliness  must  be 
enforced,  using  the  iodine  solution,  or  other  antiseptic,  such 
as  oxygenated  water  (i  :  5),  etc. 

Hypertrophy  of  the  Tonsils. 

Chronic  inflammation  of  the  tonsils,  with  permanent  in- 
crease of  tissue. 

Etiology. — This  is  specialh'  frequent  during  childhood. 
Any  nasal  obstruction,  such  as  adenoid  vegetations,  turbinai 
hypertrophy,  septal  spurs,  etc..  which  produces  mouth- 
breathing  is  an  important  cause  of  inflammation  and 
consequent  hypertrophy.  Repeated  acute  inflammatory 
attacks  also  favour  this  condition,  as  well  as  certain  general 
infectious  diseases,  such  as  measles,  scarlet  fever,  influenza, 
diphtheria,  typhoid,  etc. 


PATHOLOGY  OF  THE  PHARYNX  73 

There  are  two  forms  :  a  true  hypertrophy  and  a  pseudo- 
hypertrophy— the  former  produced  by  an  increase  of  all  the 
elements  of  the  tonsil,  while  the  latter  is  due  to  obstruction 
of  the  crypts  from  retained  secretion.  The  symptomatology 
has  been  much  modified,  since  we  know  the  symptoms  caused 
by  the  presence  of  adenoid  vegetations.  The  modification  of 
the  vocal  tone,  known  as  the  tonsillar  voice,  is  attributed  to 
the  hypertrophied  organs  interfering  with  the  proper  function 
of  the  soft  palate. 

We  may  divide  the  hypertrophies  into  three  varieties — 
(r)  the  pedunculated,  (2)  the  hooded,  (3)  the  multilobular. 

The  pedunculated  project  beyond  the  pillars.  In  the 
hooded  variety,  although  they  may  be  much  enlarged,  they 
appear  blended  with  the  anterior  pillar,  so  that  it  is  often 
difficult  to  know  where  the  one  begins  and  the  other  ends. 

In  the  multilobular  it  is  usual  to  find  one  of  the  lobes 
stretching  towards  the  base  of  the  tongue  and  almost  touch- 
ing the  epiglottis.  The  glands  at  the  angle  of  the  jaw  may 
be  enlarged,  and  also  the  adenoid  tissue  in  the  throat. 

Complications. — This  hypertrophy  predisposes  to  infectious 
tonsillitis  and  suppurative  inflammations.  Among  the  com- 
plications may  be  noted  some  reflex  symptoms,  such  as  spas- 
modic coughing,  œsophagismus,  glottic  spasm,  asthma,  etc. 

Diagnosis. — This  hypertrophy  is  easily  seen  on  depressing 
the  tongue.  It  has  to  be  differentiated  from  the  secondary 
hypertrophies  of  syphilis  by  the  history  of  the  case,  presence 
of  other  lesions,  etc.  Again,  in  examining  children  one  must 
distinguish  the  conditions,  where  the  tonsils  are  simply  pushed 
forward  by  an  excessive  straining,  by  getting  the  patient  to 
breathe  freely,  and  by  properly  placing  the  spatula  on  the 
tongue  behind  the  inferior  dental  arch. 

Lymphadenoma  is  usually  recognized  by  the  accompany- 
ing swelling  of  the  parotid  glands.  Its  excessive  develop- 
ment is  besides  unilateral.  The  course  of  the  affection  and 
histological  examination  of  a  portion  of  the  tissue  make 
diagnosis  sure. 

Treatment  :  {a)  Medical. — If  the  glands  by  their  bulk  incon- 
venience   the    patient,    or    become    the    seat    of    repeated 


74 


DISEASES  OF  THE  PHARYXX  AXD  LARYXX 


inflammations  due  to  the  crypts  and  the  microbic  products 
that  they  contain,  medical  treatment  either  fails  or  has  a 
transitory  effect. 

Astringent  gargles  are  recommended,  preferably  those 
containing  iodine,  with  accompanying  applications  of  pure 
citron-juice  or  resorcin  (i  :  loj.  which  will  have  the  effect  of 
promptly  cleaning  the  gland,  and  in  some  cases  reducing  its 
bulk.     Adrenaline  in   solution    ii:io,oco    or    1:5,000,1   will 


Fig. 


-BEHAG's    TOX5ILLOTOME.* 


produce  excellent  results  in  such  cases.  Certain  mmeral 
waters  I'sulphurous,  arsenical,  or  even  saline,)  act  favourably 
on  the  hypertrophied  tonsils.  Sprays,  gargles,  throat-washes, 
or  even  aquapuncture  may  be  used.  The  latter  consists  in 
directing  a  very  fine  jet  of  water  with  sufficient  pressure  to 
produce  a  veritable  traumatism  on  the  part  of  the  tonsil  im- 
plicated. The  inflammatory  reaction  may  clear  the  tonsillar 
ciy'pts,  and  in  some  cases  reduce  the  bulk  of  the  glands 
themselves.     It  goes  without  savin?,  that  medical  treatment 


Fig. 


-Fanhestock's  Toxsillotome. 


will  be  more  applicable  to  pseudo-hypertrophic  forms, 
caseous  tonsillitis,  chronic  tonsillitis,  etc.,  than  to  true  hyper- 
trophy. In  the  latter  it  will  be  preferable  to  reduce  or 
suppress  the  hypertrophied  parts,  as  follows  : 

(b)  Surgical. — Some  time  ago  the  tonsillotome  was  syste- 
matically used,  but  of  recent  years,  owing  to  hemorrhage 
and  other  accidents,  different  means  have  been  employed,  such 
as  ignipuncture,  the  snare  (cold  or  hotj.  or  morcellement. 

*  Guillotine  used  by  the  translator.    Edinburgh  Royal  lnfirmar\-  pattern. 


PATHOLOGY  OF  THE  PHARYNX 


75 


The  galvanic  snare  necessitates  an  elaborate  electric  in- 
stallation, and  can  be  employed  only  where  the  tonsil  is 
pedunculated,  or  when  the  organ  projects  sufficiently  to 
enable  the  wire  to  encompass  it.  The  steel  wire  should  only 
be  at  a  dull-red  heat,  to  prevent  haemorrhage,  as  well  as  the 


Fig.   t,2 — Morell-Mackexzie's  Tonsillotome. 


melting  of  the  wire.  The  cold  wire  should  be  placed  over 
the  tonsil,  tightened,  and  then  the  current  passed  through. 
This  should  be  done  interruptedly,  not  to  overheat  the  wire, 
and  so  keep  it  at  a  dull-red  heat.  Thus  the  section  is  done 
by  degrees,  and  is  finished  in  a  few  seconds.  In  more  diffi- 
cult cases  it  may  be  necessary  to  get  an  experienced  assistant 


76 


DISEASES  OF  THE  PHARYNX  AND  LARYNX 


to  draw  the  tonsil  out  so  as  to  enable  it  to  be  encompassed 
with  the  snare. 

Ignipuncture  by  the  galvano  or  thermo-cautery  requires 
the  patient  to  be  very  tractable,  and  necessitates  the  use 
of  a  gag  combined  with  a  tongue  spatula,  to  avoid  burning 


Fig.  33. — Erichsen's  Tonsil  Scissors. 

the  neighbouring  structures.  This  procedure  gives  rise  to 
serious  inconvenience  if  it  be  performed  timidly — that  is  to 
say,  by  the  aid  of  small,  deep  ignipunctures  plunged  into  the 
tonsil,  which  may  need  six,  seven,  and  even  eight  sittings. 
It  is  also  the  means  of  creating  synechiae,  which  obstruct  or 
constrict  the  crypts. 


Fig.  34. — Galvanic  Cautery  Handle. 

After  having  favoured  this  procedure,  the  author  has  now 
almost  altogether  given  it  up  for  the  above  reasons.  He 
now  employs  a  broad  knife  (galvano  or  thermo),  and  plunges 
it  from  within  outwards,  making  three  transverse  lines, 
thoroughly  cauterizing  the  tonsil  at  one  sitting.  At  the 
next  sitting  the  irregular  surface  can  be  levelled  down. 


PATHOLOGY  OF  THE  PHARYNX 


77 


Morcellement. — This  consists  in  reducing  the  tonsil  piece 
by  piece  with  special  forceps.  It  is  simple,  and  can  be  used 
equally  well  in  children  or  adults,  and  only  needs  one 
sitting. 


Fig.  35. — Dr.  Bonain's  Tonsillar  Forceps. 

The  tonsil  is  first  cocainized,  and  the  tongue  being  firmly 
pressed  down  on  the  floor  of  the  mouth,  the  forceps  is  intro- 
duced and  pieces  removed.      It  is  well  to  close  the  blades 


Fig.  36. — Ruault's  Punch-forceps  for  Morcellement  of  the  Tonsils, 
AND  even  Certain  Tumours  of  the  Pharyngeal  Cavity. 


sharply,  so  that  the  tissue  may  be  crushed  during  the  act  of 
cutting. 

It   is    important    to  observe,   before   tonsillotomy  is    per- 
formed, that  the  organs  are  not,  and  have  not  recently  been, 


78 


DISEASES  OF  THE  PHARYNX  AND  LARYNX 


inflamed.     For  a  few  days  before  the  operation  the  author 
paints  the  tonsil  with  citron-juice,  or  with  the  following: 

I^  Hydrochloride  of  cocaine 
Resorcin 
Spirit  of  peppermint  ('  alcool 

de  menthe  ')  or  tincture  of 

eucalyptus 
Glycerine 

After  the  operation  is  completed,  the  sucking  of  ice  is 
beneficial.     A  cold  gargle  should  be  prescribed  and  used  for 


30  centigrammes 

gr-5 

4  grammes 

gr.  60 

25  drops 

ïïl^xxv 

30 

n]^xxx 

Fig.  37. 


-Punch-forceps  for  the  Right  Side,  and  for  the 
Right  and  Left  Sides. 


twenty-four  to  forty-eight  hours,  and  if  necessary  ice  may  be 
put  into  it  should  there  be  any  fear  of  immediate  or  secondary 
ha:morrhage.  The  alkaline  gargle  is  the  best  for  disinfection 
of  the  throat. 

In  the  case  of  adolescents  and  adults  the  author  usually 
removes  only  one  tonsil  at  a  time,  allowing  an  interval  of  from 
eight  to  fifteen  days  between  each  operation.  Thus  should 
haemorrhage  or  other  complication  arise,  it  can  be  dealt  with 
more  easily.  If  adenoid  vegetations  be  also  present,  he  re- 
moves them  before  performing  tonsillotomy,  as  the  latter  is 
often  unnecessary  after  nasal  breathing  is  established.  It  is, 
however,  possible  to  remove  both  the  adenoids  and  the  tonsils 


PATHOLOGY  OF  THE  PHARYNX 


79 


at  one  sitting  ;  but  if  the  tonsils  are  very  large,  it  is  better  to 
remove  them  first. 

For   children    any  one  of  these   three   methods  may  be 
adopted  : 

1.  The  tonsillotome — an  excellent  method. 

2.  The  galvanic  snare. 

3.  Morcellement. 

For   adolescents    and   adults    the   two   last    methods   are 
recommended  on  account  of  possible 
haemorrhage. 

Post  -  Operative  Complications.  — 
Haemorrhage  may  be  formidable  after 
this  operation.  Fortunately,  the 
bleeding  usually  comes  from  a  large 
vessel — arterial  or  venous — which  can 
be  readily  seen  by  good  illumination. 
A  plug  of  cotton- wool  soaked  in  cocaine 
(i  :  10),  with  adrenaline  (i  :  1,000), 
equal  parts,  or  pressure  forceps  on  the 
spot,  will  usually  stop  the  bleeding. 
Where  possible,  a  ligature  may  be 
applied  over  the  forceps. 

Sometimes  the  bleeding  arises  from 
a  more  extended  area,  and  the  above 
measures  fail,  as  well  as  the  application 
of  iced  water,  oxygenated  water,  per- 
chloride  of  iron,  antipyrin,  etc.  If 
the  flow  cannot  be  checked  by  the 
thermo  or  galvano  cautery,  Escat  and 
others  recommend  ligature  of  the 
pillars  by  silk  sutures,  thus  enclosing 
the  tonsil  and  compressing  the  bleed- 
ing-point. 

Another  complication  is  the  burning  of  the  neighbouring 
tissues  by  allowing  the  instrument  to  incandesce  too  long  in 
the  mouth,  which  may  set  up  cicatricial  contractions  in  the 
soft  palate.  Acute  infectious  angina,  or  even  abscess,  may 
also  occur. 


Fig.    38.— Broca's  Ton- 
sillar Compressor. 

A,   Tampon    for   placing 
on     the     cut      tonsil  ; 

B,  external    tampon  ; 

C,  jointed      portion  ; 

D,  screw  for  approxi- 
mating the  pads  and 
producing  the  compres- 
sion. 


'8o  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

Tumours  of  the  Tonsils. 

These  may  be  divided  into  benign,  malignant,  or  mixed. 

The  benign  tumours  include  pseudo-polypoidal  hyper- 
trophy, fibromata,  papillomata,  and  cysts. 

The  malignant  growths  are  the  sarcomata  (lymphadeno- 
mata  and  lympho-sarcomata),  scirrhus,  encephaloid  and 
epitheliomata. 

Benign  Tumours. 

Symptoms. — As  a  rule,  the  symptoms  are  very  variable. 
There  may  be  none,  and  the  tumour  is  only  discovered  by 
chance  during  the  examination  of  the  throat.  If  the  tumour 
is  large  or  pedunculated,  it  may  give  rise  to  the  feeling  of  a 
foreign  body  in  the  throat,  or  a  prickling  sensation,  which 
causes  the  patient  to  clear  his  throat  and  "  hem,"  a  symptom 
formerly  attributed  solely  to  granular  pharyngitis. 

In  other  cases  spasmodic  coughing  occurs,  owing  to 
titillation  of  the  base  of  the  tongue  or  of  the  epiglottis  by 
the  growth. 

If  the  latter  is  very  large,  disturbances  in  deglutition  and 
respiration  may  occur,  with  alteration  of  the  voice  ;  but  the 
hearing  is  generally  intact,  unless  the  growth  is  high 
up  on  the  pharyngeal  wall. 

Objective  Symptoms. 

1.  Pseudo-polypoidal  Hypertrophy. — Where  one  of 
the  lobes  of  the  tonsil  has  become  prominent  and  suggests 
a  true  polypus,  microscopic  examination  shows  the  normal 
histology.  This  hypertrophy  may  be  unilobular  or  multi- 
lobular. 

2.  Papilloma. — This  is  the  most  frequent  growth,  and 
is  usually  situate  on  the  edge  of  the  soft  palate,  the  anterior 
pillar,  or  on  the  tonsil  itself.  Usually  pedunculated,  it  has 
a  mulberry-like  appearance,  is  made  up  of  small  warty  pro- 
cesses, is  of  a  rosy-grey  colour,  and  varies  in  size  from  a 
grain  of  corn  to  a  hazel-nut. 


PATHOLOGY  OF  THE  PHARYNX  8i 

3.  Fibroma. — This  may  be  pedunculated  or  sessile,  and 
is  usually  attached  to  the  mucosa  by  a  broad  base.  It  has 
a  pale  pink  or  yellowish  colour,  and  has  usually  a  rounded 
or  oval  form.  It  is  hard  in  consistence.  On  its  surface 
ecchymosis  may  sometimes  be  observed. 

4.  Adenoma. — Like  a  cyst,  this  is  a  smooth  tumour  with 
an  even  surface,  greyish,  or  of  a  rosy -grey  colour,  and 
resembling  somewhat  a  mucous  polj'pus.  It  is  very  rare, 
and  diagnosis  can  only  be  made  by  histological  examination. 

5.  Cysts. — Retention  cysts  may  contain  either  serous 
products  or  more  commonly  a  syrupy,  colloid,  yellowish 
liquid,  reddish  or  prune-coloured  if  hsemorrhagic.  Generally 
they  are  not  true  cysts,  since  they  have  no  proper  wall,  but 
are  simply  formed  through  the  obstruction  and  dilatation  of 
the  crypts. 

At  first  sight  they  resemble  fibromata  in  appearance  and 
in  hardness,  but  on  being  seized  with  the  forceps  they 
burst. 

Echinococcus  cysts  may  invade  the  tonsils.  They  are 
very  rare. 

Course. — Usually  the  progress  of  benign  tumours  is  very 
slow.  They  have  no  tendency  to  spontaneous  recovery,  with 
the  exception  of  retention  cysts,  which  may  become  inflamed 
and  burst,  and  then  constitute  an  acute  ulcerous  lacunar 
tonsillitis.  If  the  walls  are  very  thin,  their  rupture  may  be 
brought  about  by  coughing,  vomiting,  etc. 

The  other  tumours  progress  gradually  and  slowly,  and 
sometimes  attain  a  large  size  if  they  are  not  attended  to. 

Prognosis. — Good.  If  danger  supervenes  from  their  size, 
they  can  be  removed. 

Treatnient. — This  consists  in  removing  the  growth  by  the 
snare,  cautery  knife,  scissors  or  Ruault's  morcellement 
forceps. 

The  haemorrhage  is  not  free,  and  is  easy  to  stop  with  the 
thermo  or  galvano  cautery,  or  with  the  strong-pressure 
forceps  applied  to  the  bleeding  spot.  In  the  case  of  reten- 
tion or  hydatid  cysts,  the  galvano-cautery  is  followed  by 
curetting  and  the  application  of  zinc  chloride  (i  :  lo). 

6 


82  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

Malignant  Tumours. 

The  author  speaks  here  only  of  the  primary  tumours  of 
the  pharyngeal  cavity. 

Etiology. — The  causes  of  these  tumours  are  as  obscure  as 
the  etiology  of  such  forms  in  general.  They  appear  to  be 
more  common  in  men,  and  tobacco,  or  rather  the  abuse  of  it, 
seems  to  have  an  influence  on  subjects  predisposed  to  this 
malady.  On  the  other  hand,  the  author  does  not  think 
alcohol  has  the  same  serious  determinant  effect. 

Heredity  must  play  an  important  rôle  in  the  etiolog}',  but 
this  malignant  degeneration  is  seen  in  patients  having  no 
hereditary  antecedents. 

Symptoms. — At  first  these  may  be  so  slight  as  to  escape 
observation,  such  as  slight  inconvenience  in  deglutition,  a 
prickly  sensation  in  the  throat,  with  some  salivation.  After 
a  time  the  dysphagia  increases,  and  the  patient  complains 
of  pain,  increased  by  the  movements  of  deglutition  and 
mastication.  He  feels  a  continual  desire  to  cough  or  hawk, 
which  causes  him  to  expectorate  saliva  or  even  streaks 
of  blood,  and  makes  him  sick.  The  glands  at  the  angle  of 
the  jaw  become  involved.  They  vary  much  in  size,  but  one 
is  larger  than  the  others.  They  are  of  cartilaginous  hard- 
ness, adherent  to  the  underlying  structures,  and  painful  to 
the  touch.  The  voice  becomes  muffled  and  tonsillar,  and 
the  saliva  so  profuse,  that  the  patient  has  either  to  spit  or 
swallow  it. 

On  account  of  the  immobility  of  the  structures  this  act  is 
very  painful.  The  breath  is  now  very  fetid  from  the 
sphacelating  neoplasm. 

Among  certain  cancerous  subjects  there  are  very  few 
functional  symptoms  observed,  the  adenopathy  onl}^  showing 
itself  late  in  the  disease. 

Sarcoma. — This  is  usually  seen  as  a  fairly  hard  unilateral 
tumour.  The  mucous  membrane  covering  it  is  generally 
dark  grey  in  colour,  filling  up  more  or  less  the  naso-pharynx, 
and  especially  the  buccal  orifice. 


PATHOLOGY  OF  THE  PHARYNX  S3 

Lymphadenoma  or  Lympho-sarcoma  (for  these  two 

tumours  are  not  easih*  distinguished  histologically)  is 
usually  met  with  in  adults  from  thirty  to  forty  years  old. 
Though  painless,  it  interferes  with  deglutition  and  respira- 
tion. It  attacks  one  or  even  both  tonsils  simultaneously, 
without  invading  the  pillars  or  the  base  of  the  tongue. 
These  tumours  may  reach  a  good  size  before  they  ulcerate. 
The  submaxillary  and  cervical  glands  become  involved  at  an 
early  date,  and  may  extend  as  far  downward  as  the  clavicle. 
They  are  of  considerable  size,  distinct  from  each  other,  and 
painful  to  touch.  This  condition  has  been  frequently  mis- 
taken for  chronic  unilateral  hypertrophy  of  the  tonsils,  and 
surgical  intervention  has  given  rise  to  errors,  in  the  sense 
that  if  the  tumour  did  not  recur  /;z  situ,  the  glands  were  the 
seat  of  secondary  growths.  The  general  condition,  then,  is 
rapidly  aggravated.  This  adenopathy  appears  to  the  author 
to  be  the  principal  symptom  for  making  a  correct  diagnosis. 
The  glandular  enlargement  may  be  extreme,  especially  when 
the  ulcerated  and  fungous  tumours  spread  to  the  naso- 
pharynx, or  to  the  base  of  the  tongue  or  soft  palate. 

Epithelioma. — The  scirrhous  variety  is  exceptional  in 
the  throat.  Common  epithelioma  is  fairly  frequent.  It 
starts  in  an  indistinct  manner  in  the  tonsil,  uvula,  soft  palate, 
or  lingual  tonsil.  The  symptoms  are  those  of  malignant 
tumours  of  the  tonsil  in  general,  but  differ  from  sarcoma  in 
that  the  saliva  is  blood-stained  or  sanious  from  the  first,  and 
the  pain  is  also  more  severe,  neuralgic  in  character,  radiating 
up  the  head,  and  especially  to  the  ear.  These  pains  are 
aroused  by  movements  of  deglutition  and  mastication. 

On  examination  of  the  throat  a  reddish  tumour  is  seen, 
which  at  an  early  date  is  mulberry-shaped,  but  later  de- 
velops into  a  mushroom-shaped  structure,  the  head  of  which 
is  mammillated,  like  that  of  a  cauliflower.  This  is  covered 
over  in  places  with  a  diphtheroid  exudate.  There  exists 
later,  superficial  ulceration,  with  hard,  irregular  but  not  dis- 
coloured borders. 

The  course  of  the  disease  is  generally  progressive,  spread- 

6—2 


84  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

ing  from  the  tonsil  and  necessarily  involving  the  pillars,  base 
of  the  tongue,  etc.  It  may,  hov^ever,  remain  stationary  for 
several  months.  It  is  only  during  the  ulcerative  period  that 
it  rapidly  invades  the  neighbouring  parts.  Adenopathy 
frequently  very  early,  is  extensive,  and  the  other  side  may 
be  also  affected. 

Course. — At  first  this  is  slow,  but  assumes  an  acute  form 
from  time  to  time,  and  carries  off  the  patient  in  a  few  months. 
Its  duration  is  usually  from  a  year  to  eighteen  months. 
With  older  subjects  it  may  be  rather  longer.  Death  super- 
venes from  cachexia,  haemorrhage,  or  suffocation. 

Diagnosis. — This  is  at  first  difficult  to  diagnose  from  a 
chancre  or  gumma.  The  course  of  the  syphilitic  lesion  is 
more  rapid  ;  treatment,  however,  will  remove  all  doubt.  As 
many  cancerous  subjects  were  formerly  syphilitics,  it  is  im- 
portant to  know  that  specific  treatment  has  a  semblance  of 
favourable  effect  on  the  course  of  the  disease  even  in  the 
case  of  malignant  tumours;  but  if  the  treatment  with  bin- 
iodide  is  prolonged,  it  seems  to  cause  the  disease  to  advance 
at  a  more  rapid  rate. 

There  are  a  few  cases  where  it  may  be  very  difficult  to 
make  a  correct  diagnosis.  The  existence  of  deep  serpiginous 
ulceration,  with  pronounced  but  not  hard  edges,  would  favour 
syphilitic  origin,  while  a  vegetative  growth,  composed  of 
small  mammillated  projections  of  reddish  colour,  bleeding 
readily  on  being  touched,  would  be  in  favour  of  a  neoplasm. 
The  principal  points  in  regard  to  malignancy,  in  the  author's 
opinion,  are  spontaneous  pain,  blood-stained  expectoration,  with 
the  early  and  characteristic  adenopathy . 

Treatment. — When  seen  early  the  tumour,  if  on  the  uvula  or 
soft  palate,  may  be  removed.  A  cure  may  be  effected  by 
means  of  the  galvano  or  thermo  cautery.  If,  however,  the 
growth  has  its  origin  on  the  tonsil,  base  of  the  tongue,  or 
the  pillars,  it  is  quite  another  matter.  It  is  rare  that  we  do 
not  get  a  recurrence  after  operative  measures  on  those  parts. 

An  early  and  strictly  localized  epithelioma  or  sarcoma  of 
the  tonsils  may,  if  no  glandular  involvement  has  taken  place, 
be  wholly  removed,  and  a  cure  take  place  ;  but  if  the  neoplasm 


PATHOLOGY  OF  THE  PHARYNX  85 

has  invaded  all  one  side  of  the  throat  and  is  not  limited, 
operation  is  useless. 

If  an  operation  be  decided  on,  the  external  carotid  must  be 
ligatured  and  the  inferior  maxilla  resected  in  order  to  get  at 
the  diseased  parts.  Tracheotomy  is  not  indispensable,  but  the 
operator  must  be  prepared  for  it  if  necessary.  Unfortunately, 
a  cure  is  very  rare  after  such  operative  measures. 

Some  attempt  may  be  made  to  retard  the  progress  of  the 
neoplasm  in  cases  where  an  operation  is  impossible.  A 
gargle  or  paint  of  thuja  or  celandine  is  of  advantage,  as  for 
example  : 

1^  Solution  of  adrenaline  (i  :  1,000)  1  __  flT(^lxxv 

T-  .       ^    r  i_L    •  -aa    S  grammes 

Extract  of  thuja        ...  ...)         ^^  I  gr.  75 

Tincture  of  celandine               ••••--  f     ^^ 

Pure  glycerine           ...              ...j       -^  "                 iôvii 

A  teaspoonful  to  be  added  to  half  a  glass  of  tepid  water, 

and  used  as  a  gargle  several  times  daily. 

This  retards  the  growth,  and  so  helps  to  diminish  the 
difficulty  of  deglutition  and  respiration. 

Insterstitial  injections  of  the  cacodylate  or  arseniate  of 
soda  are  also  employed  with  similar  effect. 

In  confirmed  cases  measures  calculated  to  sustain  strength 
and  assuage  pain  should  be  employed  ;  but,  after  all,  radio- 
therapy gives  the  best  results. 


CHAPTER  III 

PATHOLOGY  OF  THE  LINGUAL  TONSIL 

Acute  Inflammation  (Folliculitis)  of  the  Lingual 

Tonsil. 

An  affection  limited  to  the  follicles  at  the  base  of  the  tongue. 
This  is  more  frequent  in  adults,  and  is  often  unobserved 
through  superficial  examination,  although  it  may  assume  in 
certain  cases  great  severity. 

The  distinguishing  feature  of  this  lingual  inflammation  is 
pain  elicited  by  pressure  on  the  sides  of  the  neck,  and  shoot- 
ing towards  the  great  cornu  of  the  hyoid.  Respiration  and 
phonation  are  rendered  difficult  and  painful  from  pressure 
of  the  operculum  on  the  laryngeal  aperture. 

The  existence  of  the  lesion,  the  swelling  of  the  parts 
affected,  and  the  distinct  pultaceous  coating  of  some  of  the 
follicles,  can  be  discovered  only  by  the  use  of  the  laryngeal 
mirror. 

Treatment. — This  is  the  same  as  that  of  an  ordinary  ton- 
sillitis, but  it  is  necessary  to  see  that  the  patient  should  in 
gargling  throw  his  head  well  backwards,  so  that  the  parts 
are  reached  by  the  fluid.  This  may  also  be  accomplished  by 
the  patient  saying  '  Gloo  '  whilst  gargling. 

Abscess  of  the  Lingual  Tonsil. 

The  etiology  is  just  the  same  as  that  of  all  phlegmonous 
anginse,  but  possible  erosions  of  the  mucosa  by  foreign  bodies 
or  sudden  infections  due  to  the  galvano-cautery  must  be  borne 
in  mind. 

Symptoms. — Odynphagia  and  dysphagia,  corresponding  to 
the  size  of  the  abscess,  with  pain  radiating  up  to  the  ear  on 

86 


PATHOLOGY  OF  THE  LINGUAL  TONSIL  87 

the  affected  side.  Besides  these,  we  have  the  usual  symptoms 
of  shivering,  headache,  etc.,  common  to  phlegmonous  angina. 
The  voice  and  articulation  become  thick  from  the  infiltration 
and  immobility  of  the  base  of  the  tongue.  Respiration  may 
not  be  affected,  or  only  slightly  so  ;  but  if  the  lesion  is  pro- 
nounced, respiratory  dyspnoea  may  result  ;  and  if  oedema  of 
the  epiglottis  or  of  the  folds  takes  place,  tracheotomy  may 
be  necessary  to  ward  off  asphyxia. 

Locally  very  little  beyond  a  slight  redness  may  be  seen. 
Pain  on  the  forced  depression  of  the  base  of  the  tongue  is  an 
important  symptom.  The  mirror  should  be  used.  Between 
the  glosso-epiglottic  fossse,  and,  as  a  rule,  unilateral,  the 
abscess  is  seen,  at  first  of  a  darkish-red  colour,  and  with 
a  smooth,  tense  wall.  Later  it  assumes  a  yellowish  tint,  from 
the  presence  of  pus. 

In  the  graver  forms,  when  the  abscess  is  less  localized, 
diffuse  infiltration  takes  place  of  the  whole  of  the  base  of  the 
tongue,  accompanied  by  œdema  of  the  lingual  surface  of  the 
epiglottis,  and  sometimes,  though  rarely,  of  the  aryepiglottic 
folds.  The  latter  may  be  so  much  infiltrated  as  to  interfere 
with  respiration,  which  is  also  affected  by  the  immobility  of 
the  operculum. 

Extremely  painful  to  touch,  there  may  usually  be  perceived 
in  the  swelling  a  feehng  of  tumefaction  rather  than  distinct 
fluctuation,  which  latter  is  very  difficult  to  observe.  Some- 
times fluctuation  may  be  made  out  by  pressing  over  the  base 
of  the  longue  with  two  fingers. 

Adenopathy,  though  sometimes  awanting,  is  usually 
present.  The  retromaxillary  glands,  when  swollen,  are  painful 
to  the  touch. 

Course. — This  resembles  that  of  an  ordinary  tonsillar 
abscess,  which  if  left  alone  discharges  spontaneously.  Some- 
times a  fistula  may  remain,  or  a  pocket  which,  by  discharg- 
ing imperfectly,  causes  reinfection. 

Complications. — The  most  important  are  oedema  of  the 
surrounding  structures,  interfering  with  respiration,  or 
purulent  infiltrations  of  tne  subhngual  region,  the  gravity 
of  which  we  recognize. 


88  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

The  prognosis  depends  on  the  degree  of  infiltration  and  on 
the  treatment  adopted. 

Diagnosis. — This  is,  as  a  rule,  easy  if  the  throat  is  properly 
examined  by  means  of  the  mirror.  Ludwig's  angina  (super- 
hyoidean  gangrenous  phlegmon)  should  not  be  mistaken  for 
abscess  of  the  lingual  tonsil,  as  the  symptoms  of  the  latter  are 
quite  distinctive.  Acute  abscesses  localized  to  the  epiglottis 
are  also  easily  recognized  by  the  mirror. 

Treatment. — This  is  similar  to  that  exhibited  in  phlegmonous 
tonsillitis.  As  soon  as  diagnosis  is  established,  incision,  pre- 
ferably with  the  galvano-cauter}^,  should  be  used  to  prevent 
the  possibility  of  extension.  This  is  carried  out  by  means  of 
the  mirror  after  cocainizing  the  region. 

The  galvano-cautery,  as  in  all  tonsillar  abscesses,  has  the 
advantage  of  thorough  penetration  into  the  substance,  and 
thus,  by  making  a  free  opening,  secures  efficient  drainage. 

If  the  suppurative  process  extends  to  the  floor  of  the  mouth, 
early  and  free  external  incision  should  be  made.  Tracheotomy 
is  only  to  be  carried  out  if  the  patient's  life  is  endangered  from 
interference  with  respiration. 

Chronic  Abscess  of  the  Base  of  the  Tongue. 

Chronic  suppuration  in  the  lingual  tonsil  may  be  met 
with,  but  it  has  not,  the  writer  believes,  been  noted  by  other 
authors  who  have  written  on  the  affections  of  this  fourth 
tonsil.  He  has  met  with  some  cases  :  one  that  of  a  woman 
of  fifty  or  so,  who  expectorated  pus  with  great  frequency, 
and  in  whom  the  dépression  of  the  tongue  by  the  spatula 
caused  pus  to  well  from  the  centre  of  the  lingual  tonsil. 
There  was  very  slight  redness  and  swelling  of  the  gland, 
and  no  adenitis.  From  time  to  time,  either  from  cold 
or  ingestion  of  irritant  liquid,  etc.,  acute  suppuration 
took  place,  accompanied  by  pain  and  swelling  of  the  parts. 
Occasionally  even  an  œdematous  infiltration  appeared  on 
the  lingual  surface  of  the  epiglottis  and  the  glosso-epiglottic 
folds. 

In  such  a  case  a  differential  diae^nosis  would  arise  between 


PATHOLOGY  OF  THE  LINGUAL  TONSIL  89 

a  chronic  suppurative  folliculitis,  an  adenoiditis,  or  a  suppu- 
rative cyst. 

The  treatment  consists  of  opening  the  abscess  freely,  and 
then  swabbing  the  cavity  with  a  solution  of  zinc  chloride. 

If  this  is  unsuccessful,  curetting  should  be  performed. 
It  must  be  remembered,  that  such  lesions  in  this  region 
endanrer  life. 


Hypertrophy  of  the  Lingual  Tonsil. 

A  hypertrophy  of  the  mass  of  closed  follicles  situate 
between  the  base  of  the  tongue  and  the  epiglottis. 

Etiology. — Dr.  Lennox  Browne,  in  1880,  was  the  first  to 
draw  attention  to  this  affection.  Since  that  period  other 
observers,  and  especially  Renault,  have  devoted  themselves 
to  the  subject. 

The  etiology  is  similar  to  that  of  the  other  tonsillar  hyper- 
trophies— repeated  inflammatory  attacks,  certain  infectious 
diseases,  as  measles,  influenza,  scarlatina,  rheumatism,  etc., 
seem  to  influence  its  development. 

For  many  years  we  have  drawn  attention  to  the  influence 
of  secondary  syphilis  on  this  hypertrophy,  which,  temporary 
at  first,  becomes  permanent. 

The  constant  use  of  the  voice,  either  in  singing  or  speaking, 
is  an  equally  sure  cause  of  inflammation  and  chronic  hyper- 
trophy of  this  organ. 

Although  Renault  states,  that  the  disease  occurs  specially 
between  eighteen  and  fifty-five,  we  think  with  Escat  that 
some  cases  of  persistent  coughing  in  infants  are  due  to  the 
hypertrophy  of  these  masses. 

Hypertrophy  may  also  occur  in  leukaemia  or  pseudo- 
leukaemia. 

Symptoms. — In  some  individuals  there  are  no  symptoms 
whatsoever,  and  the  condition  is  only  discovered,  as  it  were, 
by  chance. 

A  sensation  as  of  a  foreign  body  in  the  throat,  or  a  con- 
stant desire  to  clear  the  throat,  is  frequently  complained  of. 
At  other  times  there  may  be  troublesome  coughing,  and  it 


go  DISEASES  OF  THE  PHARYNX  AXD  LARYXX 

is  said  even  to  be  the  cause  of  a  variet}-  of  phar^-ngeal 
tenesmus.  In  the  case  of  professional  singers  the  author 
has  observed  huskiness,  due  most  hkely  to  congestion  of  the 
pharynx,  or  perhaps  to  excessive  vocal  efforts.  Œsophageal 
spasm,  bronchial  asthma,  syncopal  crises,  ha\-e  also  been 
noted.  These  functional  symptoms  appear  especially  during 
an  inflammatory  attack.  There  is,  however,  no  parallel 
between  the  degree  of  hypertrophy  and  the  intensity  of  this 
reaction  ;  in  fact,  the  symptoms  are  often  seen  in  individuals 
who  have  little  or  no  hypertrophy  of  the  lingual  tonsil,  and 
they  may  persist  after  the  gland  has  been  reduced  to  its 
normal  size.  They  appear  thus  to  be  due  more  directly  to  a 
general  neurotic  condition. 

By  the  laryngoscopic  mirror,  the  mass,  red  in  colour, 
varying  in  size  from  a  pea  to  a  gooseberry  seed,  can  be  seen 
lying  in  front  of  the  epiglottis.  Between  the  follicles  is  a 
network  of  more  or  less  distended  veins. 

Sometimes  the  hypertrophies  are  more  marked,  and  are 
seen  as  mammillated  masses  about  the  size  of  an  almond 
on  each  side  of  the  median  glosso-arj-epiglottic  fold.  These 
masses  are  frequently  furrowed  antero-posteriorh-  into  two 
or  three  lobes,  and  may  project  on  to  the  epiglottis.  This 
hypertrophy  spreads  lateral!}-  to  the  base  of  the  anterior 
pillars,  or  gives  rise  to  a  polypus-like  structure.  It  may  also 
join  the  palatine  tonsil,  and  thus  it  explains  how  ulceration 
in  the  one  passes  to  the  other  tonsil 

The  histology  of  this  hypertrophy  resembles  that  of  the 
buccal  tonsil. 

Course. — As  a  rule  the  hypertrophy  remains  stationary,  but 
in  some  cases,  from  repeated  inflammatory  attacks,  it  reaches 
a  large  size. 

It  may  remain  for  an  indefinite  time,  but  it  has  a  tendency 
to  diminish,  and  even  disappear,  in  the  aged. 

The  prognosis  is  benign,  but  is  graver  in  the  case  of  those 
who  use  their  voices  as  orators,  singers,  from  the  vocal 
disturbance  it  causes.  In  neurotics  also  it  induces  disturb- 
ance from  the  choking  sensation  in  the  throat. 

Diagnosis. — In   addition    to    those  symptoms  enumerated 


PATHOLOGY  OF  THE  LINGUAL  TONSIL  91 

above,  we  have  some  which  are  associated  with  what  is 
termed  the  parsesthesia  of  the  larynx. 

Secondary  syphiHs  may,  perhaps,  be  thought  of,  but  the 
presence  of  buccal  patches,  roseola,  adenopathy,  etc.,  should 
remove  any  doubt. 

Treatment. — If  the  tonsil  is  not  large  and  if  it  is  only 
inflamed,  gargles  or  pigments  may  be  used,  as  : 

R  Iodine             ...              ...     30  centigrammes  gr,  5 

Iodide  of  potassium      ...     40             ,,  gr- 6 

Laudanum  (Sydenham's)       4  grammes  oi 

Glycerine        ...              ...   120         ,,  5iiiss 

Or— 

Be  Antipyrin)  __  rgr.  75 

T5  •       -      ...  ...  aa  5  grammes  < 

Kesorcm   j  -^  *=  L  gr.  75 

Cherry-laurel  water       ...      15         ,,  3iv 

Glycerine        ...  ...    150         ,,  giv 

A  teaspoonful  to  be  added  to  half  a  glass  of  tepid  water 

for  use  as  a  gargle  thrice  daily. 

The  above  may  also  be  employed  pure  as  a  paint  once 
or  twice  a  week. 

If  this  should  prove  unsatisfactory,  then  the  following  may 
be  employed  : 

R  Antipyrin 

Tincture  of  guaiacum 
Spirit  of  peppermint  ('  alcool 

de  menthe  ') 
Glycerine 

A  teaspoonful  to  half  a  glass  of  tepid  water,  to  be  used  as 
a  gargle  morning  and  evening,  or  pure,  as  a  paint  occasionally. 

If  the  masses  are  large  enough  to  cause  annoyance,  they 
should  be  removed  by  means  of  the  galvanic  knife,  which 
should  be  applied  flat,  taking  care  to  penetrate  the  tissue. 
Only  one  side  should  be  done  at  once,  in  order  that  degluti- 
tion m.ay  not  be  disturbed  too  much. 


5  grammes 

gr-75 

15 

I1]^ccxl 

10 

ni^clx 

100 

giii 

92  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

If  the  tonsil  is  very  prominent,  it  should  be  removed  by  a 
tonsillotome  or  a  morcellement  forceps.     The  cold  or  gal- 


FiG.  39. — Forceps  for  the  Lingual  Tonsil. 

vanic  snare  can  also  be  used,  the  wire  being  appropriately 
bent  to  encircle  the  mass. 


Fig.  40. — Lennox  Browne's  Tonsillotome,  slightly   curved  to  seizî 
AND  remove  the  Hypertrophied  Lingual  Tonsil. 


Some  authors  recommend  the  curette  as  efficient.     The 
subtonsillar  tissue  should  not  be  touched,  as  cicatrices  result, 


PATHOLOGY  OF  THE  LINGUAL  TONSIL 


93 


which  may  set  up  a  condition  more  painful  and  troublesome 
than  that  caused  by  the  hypertrophied  tonsil. 

After  the  operation  the  patient  should  be  kept  in  his  room, 


Jll^^^g''    ''•*  ""'  l/:.:FT-x^iiiiiiiiggEaillMg 


Fig.  41.— Behag's  Tonsillotome. 

especially  in  winter,  from  twenty-four  to  forty-eight  hours, 
and  directed  to  use  an  emollient  gargle. 


Cysts  of  the  Lingual  Tonsil  and  of  Bochdaleck's 

Canal. 

German  authorities  have  described  under  this  name  a  little 
blind  duct,  which  opens  into  the  foramen  caecum.  According 
to  Verchère  and  Dénucé  it  exists  in  about  one  in  four  of  the 
individuals  examined.  From  the  foramen  it  is  directed 
downwards    to    the    median    glosso  -  epiglottic    fold.       The 


Fig.  42. — Erichsen's  Tonsil  Scissors. 

duct  is  richly  provided  with  glands,  and  is  covered  by 
cylindrical  epithelium,  furnished  with  cilia.  From  this 
diverticula  sometimes  pass  into  the  substance  of  the  genio- 
hyo-glossus  muscle.  It  is  from  the  occlusion  of  this  canal 
that  cysts  are  said  to  start.  These  vary  much  in  bulk, 
and  reach  the  size  of  a  gooseberry-seed  or  a  small  walnut. 
They  occupy  the  entire  substance  of  the  tongue,  and  become 


94  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

SO  large  as  to  interfere  with  respiration  from  pressure  on 
the  epiglottis. 

Externally  these  cysts  show  no  distinctive  features,  and  it 
is  only  from  their  position,  and  from  the  character  of  the 
fluid  contained  in  them,  that  a  diagnosis  can  be  made.  The 
contents  consist  of  mucus  with  cylindrical  epithelial  cells, 
which  have  become  detached  from  the  walls  of  the  canal. 
From  infection  we  have  the  chronic  suppuration  already 
described. 

In  addition  to  those  originating  from  the  thyro-lingual 
canal,  true  glandular  cysts  occur,  formed  from  the  dilatation 
of  a  canaliculus,  or  of  a  gland  in  that  region.  These  are 
situate  either  on  the  lingual  surface  of  the  epiglottis  or  on 
the  median  or  lateral  glosso-epiglottic  fold. 

In  appearance  they  are  yellowish  and  globular,  with 
smooth  walls,  traversed  by  a  fine  vascular  network.  They 
are  hard,  and  the  contents  are  generally  liquid,  colloid,  or 
even  purulent.  These  cysts  also  possess  cilia  in  their 
walls.  The  author  is  inclined  to  think  that  diagnosis  is 
established  more  from  the  situation  than  from  the  nature  of 
the  contents. 

Treatment. — ^Whatever  may  be  the  nature  of  the  retention 
cyst,  the  treatment  is  the  same — viz.,  incision,  evacuation  of 
the  contents,  and  the  removal  of  part  of  the  cyst  wall.  The 
incessant  movements  of  the  tongue  and  the  constant  passage 
of  food  prevent  the  closing  of  the  wound,  and  thus  favour 
the  secondary  infection  of  its  edges,  thereby  contributing  to 
the  entire  removal  of  the  neoplasm. 

Varix  of  the  Base  of  the  Tongue. 

In  the  examination  of  the  larynx  or  lingual  tonsil  it  is 
common  to  see  two  or  three  venous  clusters  formed  by 
the  anastomosing  of  veins,  which  join  the  internal  jugular. 
These  violet,  knotted,  and  cord-like  masses  vary  in  size, 
and  are  often  seen  in  old  people. 

In  addition  to  this  superficial  varix,  there  are  usually  some 
deeper  clusters.  These  do  not  really  exhibit  any  func- 
tional or  objective  symptoms  except  haemorrhage,  produced 


PATHOLOGY  OF  THE  LINGUAL  TONSIL  95 

generally  by  the  deglutition  of  irritants,  as  spiced  food  or 
alcohol. 

The  parsesthesia,  which  is  sometimes  complained  of, 
belongs  more  properly  to  a  true  neurosis  of  the  throat. 
Though  the  quantity  of  blood  expectorated  is  small,  it 
frightens  the  patient,  and  makes  him  seek  advice,  as  he  is 
apprehensive  of  phthisis  pulmonalis.  These  masses  bleed 
readily. 

Treatment. — Astringent  gargles,  as  the  following  : 


aa 


aa 


L     4  grammes 

(gr.  60 
[gr.  60 

f  gr.  60 

^5 

llTLccxl 

5 

TTVlxxx 

130 

§iiif 

J^  Biborateof  soda  ^ 
Antipyrin  / 

Extract  of  krameria  ] 
Tincture  of  guaiacum  J 
Tincture  of  eucalyptus 
Glycerine    ... 

A  teaspoonful  of  this  to  be  added  to  half  a  glass  of  tepid 
water.     Gargle  the  throat  two  or  three  times  a  day. 

If  the  haemorrhage  is  excessive  and  the  bleeding  spot  is 
clearly  seen,  the  galvano-cautery  can  be  employed  with 
success. 

Benign  Tumours  of  the  Lingual  Tonsil. 

Symptoms. — The  functional  symptoms  of  these  relatively 
rare  tumours  vary  from  the  sensation  of  a  foreign  body  in 
the  throat  to  grave  respiratory  interference.  Deglutition, 
usually  easy,  is  sometimes  rendered  difficult  in  consequence 
of  mechanical  impediment  to  the  food,  or  by  the  passage  of 
the  bolus  into  the  air  tract. 

Respiration  is  only  impeded  when  the  neoplasm  is  so 
large  as  to  press  down  on  the  epiglottis.  This  is  especially 
seen  in  children. 

Cough  may  be  absent,  but  is  sometimes  spasmodic,  and 
brought  on  by  phonation  or  deglutition.  It  may  be  accom- 
panied by  nausea.  The  voice  is  changed,  and  becomes 
muffled  or  nasal. 

The  objective  examination  may  be  made  with  an  ordinary 


96  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

tongue-depressor,  but  preferably  with  Kirstein's  or  Escat's. 
The  laryngoscopic  mirror  may  also  be  employed.  The 
latter  method  has  the  advantages  of  causing  less  nausea  and 
of  being  more  easily  carried  out. 

The  following  neoplasms  are  found  in  this  locality  : 

1.  Papilloma. — This  is  a  rare  neoplasm.  It  shows  a 
mulberry-like  structure,  with  characteristic  rosy-grey  colour, 
and  varies  in  size,  being  pedunculated. 

2.  Fibroma. — This  is  usually  associated  with  osseous, 
lipomatous,  myxomatous,  or  cartilaginous  tissue,  either  pedun- 
culated or  sessile,  varying  in  size  from  a  haricot  bean  to  a 
mandarin  orange  or  billiard-ball.  Yellowish  in  colour  and 
of  smooth  surface,  it  is  usually  circumscribed  and  encap- 
sulated in  the  substance  of  the  tongue.  If  this  tumour 
contains  cartilaginous  or  bony  tissue,  it  is  hard  and  nodular. 

It  has  no  tendency  to  ulcerate.  Some  authors  have  noted 
cases  where  spontaneous  haemorrhage  has  taken  place, 
similar  to  that  seen  in  the  fibrous  polypi  of  the  naso-pharynx, 
but  this  the  author  has  never  seen. 

3.  The  Lipoma  resembles  the  fibroma  very  much.  It 
varies  in  size,  and  has  a  yellowish  colour.  Lobulated 
and  soft,  it  is  situate  just  below  the  mucous  membrane, 
which  forms  a  capsule.  Its  course  is  slow.  Though  usually 
sessile,  it  may  be  pedunculated. 

4.  Pure  Chondroma  and  Adenoma  of  the  lingual  tonsil 
are  very  rare. 

5.  Angioma  of  the  lingual  base  is  fairly  common.  It 
is  usually  congenital,  and  associated  with  analogous  tumours 
elsewhere. 

They  are  flabby,  of  a  bluish  colour,  irregular  in  shape, 
and  frequently  of  a  mulberry-like  appearance.  They  are 
reducible  in  some  cases.  If  their  walls  rupture,  serious 
haemorrhage  may  result. 

6.  Mixed  Tumours.  —  Fibro-lipomatous,  myxomatous, 
and  even  chondromatous  elements,  are  present.  They  are 
nearly  all  encapsulated,  and  easily  enucleated. 

7.  Lingual  Goitre. — This  is  developed  at  the  expense 
of  an   accessory  thyroid  gland.      According  to   Curtis  and 


PATHOLOGY  OF  THE  LINGUAL  TONSIL 


97 


Gaudier,  lingual  goitre  occurs  most  frequently  in  females 
— usually  in  adults.  Its  size  varies  considerably,  from  a 
cherry  to  a  hen's  e^g. 

This  lesion  is  usually  accompanied  by  hypertrophy  of  the 
lingual  tonsil  ;  the  bloodvessels  are  well  developed,  which 
accounts  for  the  great  vascularity  of  the  goitre.  It  may  be 
movable  and  free,  but  is  usually  immobile  and  buried  in  the 
substance  of  the  base  of  the  tongue. 

Haemorrhage  may  occur,  but  it  is  not  characteristic.  It 
is  interesting  to  note,  that  in  some  of  those  cases  the  prin- 
cipal thyroid  gland  is  absent  (Curtis  and  Gaudier).  The 
development  of  those  morbid  productions  is  not  well  known, 


Fig.  43. — Angioma  of  the  Base  of  the  Tongue,  occupying  the 
Lingual  Tonsil  on  the  Left  Side. 


as  the  patient  only  complains  when  the  growth  has  attained 
an  excessive  size  {egg,  walnut,  etc.). 

Prognosis  is  good.  Even  when  the  tumours  are  of  large 
size  and  interfere  with  deglutition  and  respiration,  they  very 
rareh'  cause  death. 

Treatment. — Removal  by  means  of  excision,  morcellement, 
enucleation,  the  cold  or  galvano  snare,  according  to  the  site 
and  volume  of  the  tumours.  In  vascular  tumours  bipolar 
electrolysis  or  galvano-section  is  recommended. 

Lingual  goitre  is  similarly  treated,  but  in  order  to  extir- 
pate it,  an  external  operation  should  be  performed  by  means 
of  a  mesial  incision. 


98  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

One  of  the  various  methods  employed  is  a  suprahyoid 
mesial  incision,  extending  from  the  inferior  maxilla  to  the 
hyoid  bone.  This  does  not  give  easy  access  to  the  growth. 
Wolff's  transmaxillary  method  is  no  better  in  that  respect, 
and  leaves  too  large  a  wound.  The  author  prefers  the  trans- 
hyoidean  incision  recommended  by  Curtis,  Gussenbauer,  and 
Vallas.  It  a,dmits  of  easy  access  to  the  base  of  the  tongue, 
and  is  almost  bloodless.  If  a  preliminary  tracheotom.y  be 
performed,  so  that  the  air-passages  can  be  plugged  and  the 
■chloroform  continued  to  be  administered  through  the  canula, 
a  relatively  easy  operation  can  be  performed.  The  author 
has  practised  it  several  times,  and  always  with  an  excellent 
result.  After  removal  of  the  tumour  the  two  edges  of  the 
lingual  wound  should  be  brought  together  with  deep  catgut 
sutures,  and  in  the  same  way  the  two  fragments  of  the  hyoid 
bone  are  joined.  The  muscles  are  also  sutured  with  catgut, 
but  the  skin  with  horsehair.  No  drainage-tube  is  required, 
as  there  is  no  tendency  towards  suppuration.  If,  however,  a 
local  infection  should  take  place,  a  drain  can  be  easily  intro- 
duced by  opening  the  sutures,  etc. 

The  tracheal  canula  can  be  removed  in  forty-eight  hours 
— if  there  is  no  serous  infiltration,  which  might  interfere 
with  respiration.  If  the  buccal  route  be  chosen,  either  with 
or  without  tracheotomy,  the  patient  must  be  put  into  Rose's 
posture,  to  prevent  the  blood  passing  into  the  respiratory 
passage.  It  must  be  remembered  that  in  those  benign 
tumours  enucleation  can  be  accomplished,  and  the  operation 
thereby  facilitated  very  much. 


CHAPTER  IV 

PATHOLOGY  OF  THE  SOFT  PALATE 

Defects  of  Conformation. 

These    are    velo-palatine    insufficiency,    bifid    soft    palate, 
absence  of  the  pillars,  and  congenital  perforations. 

Velo-palatine  Insufficiency.  —  Lermoyez,  in  1892, 
first  drew  attention  to  this  condition,  which  is  characterized 
by  more  or  less  shortening  of  the  soft  palate.  It  is  very 
common  in  children,  and  is  invariably  present  in  those  who 
have  been  subjected  to  a  urano- staphylorrhaphy,  or  even 
simple  division  of  the  palate,  in  spite  of  the  wide  liberating 
lateral  incisions. 

The  chief  symptom  is  nasal  speech,  more  or  less  resembling 
that  occurring  in  children  affected  with  paresis  or  paralysis 
of  the  palate,  but  there  is  no  regurgitation  of  fluids  through 
the  nose.  This  defect  in  articulation  is  due  to  the  failure  of 
the  palate  completely  to  close  the  naso-pharyngeal  cavity 
during  the  emission  of  certain  sounds,  and  has  been  described 
by  Kussmaul  as  '  rhinolalie  ouverte.'  It  is  easily  diminished, 
or  temporarily  stopped  by  closing  the  anterior  nares  of  the 
child.  Examination  readily  reveals  the  shortening  and 
tension  of  the  palate,  which  can  only  be  imperfectly  elevated 
and  approximated  to  the  posterior  wall.  In  those  cases  the 
uvula  is  nearly  always  found  to  be  small  and  badly  developed. 
Egger  draws  attention  to  a  slight  submucous  notching  of  the 
posterior  portion  of  the  palatine  vault,  which  is  common 
among  those  operated  on  for  '  gueule-de-loup.'  Adenoid 
vegetations  are  frequently  present  in  this  affection,  and  if 
abundant,  they  may  prevent  the  palate  from  rising,  and  to  a 
certain  extent  simulate  shortening  of  the  organ. 

99  7—2 


loo  DISEASES  OF  THE  PHARYNX  AXD  LARYNX 

Treatment. — In  ver}-  marked  cases  occurring  in  children 
and  adolescents  free  lateral  incisions  may  be  made. 

Bifid  Soft  Palate. —The  bifid  state  of  the  soft 
palate,  the  mildest  form  of  which  is  the  bifidity  of  the 
uvula,  generally  occurs  with  congenital  divisions  of  the 
palatine    vault  and    hare-lip.      This    defect    gives    rise  to   a 


Figs.  44,  45.— Volsellum,  Str-^ight  ok  Curved,  and  Straight 
Bistoury. 


series  of  vocal  disorders,  which  resemble  those  caused  by 
velo  -  palatine  insufficiency.  The  sole  remedy  is  staphy- 
lorrhaph}'. 


Fig.  46.— Dutch  Needle,  Highly  Curved  to  Suture  Palate. 


Absence  of  the  Pillar.— The  author  once  saw  the 
posterior  pillar  absent,  giving  the  pharynx  a  peculiar  appear- 
ance. The  absence  of  cicatrization,  etc.,  precluded  the 
possibility  of  disease. 

Congenital  Perforation.— This  defect  consists  in  the 
loss  of  substance  of  the  lateral  parts  of  the  pharynx  at  the 
level  of  the  pillars.  These  perforations  are  usually  sym- 
metrical— sometimes  unilateral,  vertical,  oval,  without  any 
trace    of    cicatricial    tissue.      They   are    congenital,   though 


PATHOLOGY  OF  THE  SOFT  PALATE 


lOI 


long  regarded  as  acquired,  but  cause  no  trouble,  except  when 
particles  of  food  enter  and  produce  slight  inflammation. 


Fig.  47. — Absence  of  the  Posterior  Pillar  (Moure).    (Drawn 
FROM  Nature.) 


Fig.  48. — Congenital  Perforation  of  the  Anterior  Left  Pillar. 


If  the  patients  are  inconvenienced  by  those  openings,  it  is 
easy  to  afford  relief  by  paring  the  edges  and  joining  them. 
with  the  help  of  one  or  two  sutures  of  Florence  hair. 


DISEASES  OF  THE  PHARYNX  AND  LARYNX 


Fig.  49. — Congenital  Perforation  of  the  Two  Anterior  Pillars. 

Inflammation  of  the  Uvula. 

In  some  cases  acute  inflammations  of  the  pharynx  are  con- 
fined to  the  palatal  appendix.  The  same  causes  which 
produce  acute  diffused  catarrhal  angina  or  folliculitis  make 


Fig.  50.— Acute  Œdema  of  the  Uvula  (Acute  Uvulitis). 

the  uvula  swell,  become  of  a  rosy  tint,  oedematous,  and 
resemble  the  air-bladder  of  a  fish.  This  inflammation  some- 
times occurs  in  a  few  hours — twelve  to  twenty-four. 


PATHOLOGY  OF  THE  SOFT  PALATE  103 

The  main  outstanding  symptom  is  the  sensation  of  a  foreign 
body  moving  in  the  pharynx,  and  creating  a  continual  desire 
to  swallow. 

Phonation  is  dull  and  nasal,  but  no  pain  is  felt. 

Treatment  consists  in  the  excision  of  the  extremity  of  the 
uvula,  or  by  scarifying  it  with  the  bistoury  or  the  galvano- 
cautery.  First  cocainize  the  uvula,  and  while  supporting 
the  organ  with  a  spoon,  etc.,  make  a  series  of  fairly  deep 
vertical  incisions.  An  emollient  gargle  may  now  be  given, 
and  a  cure  will  ensue  in  from  twenty-four  to  forty-eight  hours. 

Haematoma  of  the  Soft  Palate  and  of 
the  Uvula. 

Apart  from  every  sign  of  cachexia  or  purpura,  there  is  seen 
true  haemorrhage  on  the  anterior  surface  of  the  soft  palate, 
or  at  the  level  of  the  uvula.  This  lesion  occurs  durmg 
meals,  and  is  independent  of  the  nature  of  the  food  taken. 

It  is  known  as  haematoma,  submucous  haemorrhage,  or 
uvular  apoplexy. 

It  appears  suddenly,  with  a  characteristic  blackish  suffusion, 
raising  the  mucous  membrane,  like  that  seen  in  pemphigus. 

This  haemorrhagic  tumour  may  burst  spontaneously  or 
disappear  by  absorption,  leaving  no  trace  after  two  or  three 
days. 

Relaxed  Uvula, 

Etiology. — Prolongation  of  the  uvula  is  not  rare  in  the 
various  chronic  affections  of  the  pharynx.  It  occasionally 
occurs  as  a  defect  in  children,  also  in  paralysis  of  the  soft 
palate  and  of  the  pharynx.  Very  long  uvulae  may  also  be 
observed  in  aged  patients. 

The  symptoms  may  be  benign  or  assume  a  grave  aspect— 
a  dry,  painful  cough,  produced  by  a  tickling  irritation  in  the 
throat,  becoming  spasmodic  or  suffocating  during  the  night. 
Sir  Morell  Mackenzie  has  noted  nausea,  due  to  the  same 
cause. 

This  disease  is  easily  diagnosed  by  direct  examination,  but 


I04 


DISEASES  OF  THE  PHARYNX  AND  LARYNX 


its  aspect  varies  at  different  stages.  The  uvula  may  even 
touch  the  teeth,  owing  to  the  relaxation  of  the  levator  palate 
muscle. 

Treatment. — Astringents  may  have  some 
effect,  but  the  simplest  method  is  the 
abscission  of  the  affected  part.  To  accom- 
plish the  latter,  cocainize  the  organ,  grasp 
the  end  with  long  forceps  held  in  the  left 
hand  ;  then  hold  in  the  right  a  pair  of 
curved  scissors,  and  cut  at  the  end  of  the 
muscular  portion,  thus  leaving  a  uvula 
large  enough  to  fulfil  its  function.  The 
post  -  operative  treatment  consists  of 
emollient  gargles,  lasting  from  three  to 
four  days,  and  cool  semi-solid  food. 

If,  as  is  frequent,  very  free  bleeding 
occurs,  it  may  be  stopped  by  applying  the 
forceps  or  a  ligature  to  the  part  affected. 

Syphilis  of  the  Soft  Palate. 

The  soft  palate  and  the  pharynx  are 
most  frequently  attacked  by  tertiary 
syphilis.  In  the  circumscribed  gum- 
matous form  there  appears  a  smooth, 
red,  fairly  defined,  rounded,  somewhat 
painful  swelling  at  the  junction  of  the 
soft  palate  and  the  vault,  or  on  the  soft 
parts  themselves  above  the  uvula,  or  on 
the  sides,  without  other  symptoms  than 
a  slight  inconvenience  in  deglutition 
and  phonation.  If  treatment  is  not 
carried  out  soon,  the  central  part  of  the  swelling  becomes 
hollowed,  showing  one  or  more  anthracoid,  greyish,  cup- 
shaped  depressions,  which  speedily  become  ulcerated,  with 
red,  well-defined  edges,  on  a  palish  background.  Gradually 
a  velo-palatine  perforation  supervenes,  with  consequent  com- 
plications—  modification  of  the  voice  and  nasal  regurgitation. 
The    ulceration    becomes   graduallv    more    extensive,    the 


Fig.  51. — MoRELL 
Mackenzie's  Uvulo 

TOME. 


PATHOLOGY  OF  THE  SOFT  PALATE 


105 


parts  affected  blending  together  and  producing  extensive 
destruction  of  the  pharyngeal  tissue.  The  uvula  becomes 
an  irregular  fungoid  mammillated  stalactite  in  the  middle  of 


Fig.  52. — Waren's  Scissors  for  Excision  of  the  Uvula. 

a  serpiginous  ulceration,  which  extends  to  the  pillars,  the 

tonsils,  the  base  of  the  tongue,  and  even  to  the  pharyngeal  wall. 

This  grave  form  of  syphilis  is  fortunately  very  rare,  because 


Fig.  53. — Tertiary  Perforation  Situate  at  the  Junction  of  the 
Soft  Palate  and  the  Vault  (Cicatricial  Synechia). 

usually,  on  a  diagnosis  being  made,  treatment  arrests  further 
development.  As  a  result  of  those  gummatous  ulcerations, 
perforations  or  stellate  cicatrices  of  a  yellowish  appearance 
occur  on  a  pale  mucous  membrane. 


io6  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

In  some  diffused  gummata,  which  are  rarer,  the  soft  palate 
has  a  reddish  surface,  partly  infiltrated  and  immobile,  whence 
very  marked  nasalization,  regurgitation,  and  often  painful 
deglutition  may  occur. 

The  gummata  originate  on  the  posterior  surface  of  the 
soft  palate  or  in  the  nasal  region,  and  are  visible  only  when 
perforation  occurs,  as  a  small  greyish  indentation  with  red 
edges.  The  rhinoscopic  mirror  must  be  employed  to  deter- 
mine the  exact  extent  of  the  disease.  In  these  posterior 
forms  vocal  disturbances,  difficulty  in  swallowing,  with 
tinnitus  and  pains  in  the  ears,  early  occur  as  functional 
symptoms.     These  are  frequently  unobserved. 

The  fairly  rapid  course  of  the  disease  and  the  appearance 
of  the  lesion  are  sufficiently  characteristic  to  render  diagnosis 
easy.  The  use  of  biniodide  solution,  with  hygienic  treat- 
ment, peroxide  of  hydrogen,  and  borate  or  salicylate  of  soda 
gargles,  is  recommended. 

Paralysis  of  the  Soft  Palate. 

Etiology. — Paralysis  of  the  soft  palate  is  often  due  to 
diphtheria.  It  occurs  in  any  type  of  this  disease.  The 
characteristic  signs  usually  appear  on  convalescence  from 
eight  to  ten  days  after  the  apparent  cure. 

Paralysis  is  seen  in  some  acute  diffuse  non-diphtheritic 
anginse.  It  may  originate  in  a  tonsillar  abscess,  in  those 
cases  appearing  on  the  affected  side,  or  as  the  result  of 
lesions  of  the  nerve-centres,  haemorrhages,  tumours,  etc.,  or 
of  peripheral  neuritis. 

Symptoms. — Phonation  becomes  nasal,  due  to  the  relaxa- 
tion of  the  structure  whose  function  it  is  to  close  the  naso- 
pharyngeal cavity.  The  patients  are  unable  to  pronounce 
certain  consonants  :  a  b  becomes  an  ni,  and  a.  d  an  «  ;  and, 
in  addition,  they  can  neither  blow  nor  suck.  Deglutition  is 
equally  interfered  with  ;  the  naso-pharynx,  being  widel}'  open, 
permits  the  regurgitation  of  liquids. 

These  paralyses  are  most  frequently  accompanied  by 
diminution  or  loss  of  sensibility,  and  in  consequence  frag- 


PATHOLOGY  OF  THE  SOFT  PALATE  107 

ments  of  food  find  their  way  into  the  trachea  and  cause 
spasmodic  coughing.  Death  has  even  ensued.  In  grave 
cases  the  paralysis  extends  to  the  pharyngeal  muscles. 

If  the  paralysis  is  partial,  the  voice  and  the  deglutition 
are  less  affected  ;  the  regurgitation  takes  place  only  when 
the  patient  swallows  too  greedily  or  carelessly. 

When  paralysis  is  complete  it  may  be  observed,  on  the 
mouth  being  opened  and  the  tongue  depressed,  that  during 
the  pronunciation  of  the  sound  '  ah  '  the  soft  palate  remains 
quite  motionless  and  relaxed  at  the  level  of  the  pharynx. 
The  uvula  remains  flaccid,  and  the  paralyzed  portion  may 
be  touched  without  causing  any  movement  towards  the 
naso-pharynx. 

Course,  Duration,  Termination.  —  Paralysis  of  infectious 
origin  lasts  for  several  weeks  or  months.  It  usually  dis- 
appears gradually,  either  spontaneously  or  under  treat- 
ment. If  the  loss  of  movement  is  due  to  a  central  lesion 
or  to  peripheral  neuritis,  it  follows  the  course  of  that 
disease. 

Diagnosis. — The  difficulties  of  phonation  and  deglutition 
are  so  well  defined  as  to  be  alone  sufficient  to  determine  the 
diagnosis. 

Velo-palatine  Hemiplegia. — As  the  result  of  certain 
tumours,  of  fracture  of  the  base  of  the  skull,  of  tubercular  or 
cancerous  adenitis,  paralysis  of  one  side  of  the  soft  palate 
may  take  place.  It  may  also  appear  as  a  sequel  of  bulbar 
paralysis  or  syringomyelia. 

It  may  happen  that  post-diphtheritic  paralysis  may  com- 
mence in  the  one  side  and  pass  to  the  other,  or  remain  on 
the  side  orginally  affected. 

Pathological  Anatomy. — M.  Lermoyez  has  shown  that  this 
disease  is  not  due  to  a  lesion  of  the  facial  nerve,  as  previously 
supposed,  but  to  an  alteration  of  the  vago-spinal,  which 
innervates  the  muscles  of  the  soft  palate,  excepting  the 
tensor  palati.  The  alteration,  according  to  Escat,  may  be 
due  to  inflammatory  or  degenerative  neuritis  from  con- 
striction or  destruction  of  the  vago-spinal.  The  disease 
occurs  not  only  in  adults,  but  in  children. 


io8  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

Symptoms. — The  functional  symptoms — viz.,  nasalization 
and  regurgitation  of  fluids — are  less  marked  than  in  complete 
paralysis,  and  are  unilateral. 

On  examination  of  the  pharynx,  one  side  of  the  soft  palate 
is  seen  to  be  raised,  while  the  other  remains  immobile, 
causing  a  very  characteristic  deformity.  The  deviated  uvula 
is  drawn  to  the  healthy  side,  which  on  contraction  becomes 
markedly  concave. 

Escat  adds  to  those  symptoms  tachycardia,  due  to  insuffi- 
cient action  of  the  vago-spinal,  and  a  cough  of  a  whooping 
nature. 

Diagnosis. — The  diagnosis  of  this  hemiplegia  is  easily 
made  by  direct  examination.  Interrogation  determines 
whether  the  paralysis  is  due  to  a  pharyngeal  inflamma- 
tion or  to  a  motor  nerve  lesion.  In  the  latter  case  velo- 
palatine  paralysis  is  always  accompanied  by  similar  changes 
in  the  muscles  of  the  larynx. 

The  cause  of  the  nerve  changes  need  now  alone  be  sought 
for.  A  full  examination  and  interrogation  of  the  patient 
will  enable  one  to  determine  the  diagnosis. 

Prognosis  depends  on  the  nature  and  seat  of  the 
lesion. 

Treatment. — The  treatment  will  depend  on  the  cause  and 
nature  of  the  disease. 

Post-inflammatory  paralysis  generally  disappears  of  its  own 
accord.  It  is  often  the  same  with  slight  post-diphtheritic 
paralysis.  However,  in  grave  cases,  injections  of  serum,  in 
doses  regulated  by  the  age  of  the  patient  and  the  severity  of 
the  attack,  should  be  made.  Tonic  treatment  (arsenic, 
strychnine)  favours  recovery. 

In  both  cases  electrical  treatment  applied  to  the  uvula  and 
the  nape  of  the  neck  simultaneously,  or  .with  both  poles  in 
the  mouth,  will  assist  muscular  contractibility  and  shorten 
the  course.  Regurgitation  gradually  disappears,  but  the 
voice  remains  unaltered  till  physiological  recovery  is 
complete. 


PATHOLOGY  OF  THE  SOFT  PALATE  109 

Tumours  of  the  Soft  Palate. 

Benign  Tumours. 

There  are  seen  on  the  soft  palate,  the  pillars,  or  uvula, 
various  benign  tumours— papillomata,  fibromata,  enchondro- 
mata,  myxomata,  angiomata,  lipomata,  adenomata,  and 
dermoid  tumours. 

Etiology  is  as  yet  rather  obscure.  The  growths  only  occur 
in  adults,  and  according  to  Bosworth,  with  whom  the  author 
agrees,  in  women  more  than  men,  in  the  proportion  of  two 
to  one.  The  symptoms  vary  much,  according  to  the  nature 
and  bulk  of  the  growth  and  its  situation. 

The  growth  may  escape  observation,  but  when  the  tumour 


Fig.  54. — Diagrammatic  Appearance  of  a  Fibroma  of  the  Uvula 
AND  of  a  Congenital  Division  of  the  Right  Anterior  Pillar. 
(After  Meyjes.) 

is  pedunculated  (papillomata)  and  titillates  the  larynx,  it 
may  incite  '  hemming  '  or  even  spasmodic  cough.  Besides, 
when  it  has  attained  a  certain  size,  nasal  phonation  and 
alalia  occur,  with  disturbances  of  deglutition,  accompanied 
by  regurgitation.  Sometimes  even  respiration  may  be 
impeded,  especially  during  the  night. 

The  appearance  of  the  pharynx  varies  somewhat,  according 
as  the  tumour  contents  are  solid  or  liquid. 

SOLID    TUMOURS. 

Fibroma,  which  is  seated  very  often  on  the  soft  palate.  It 
is  rose-tinted,  white,  or  yellowish.  A  very  delicate  vascular 
network  covers  its  surface.  Usually  it  is  formed  of  one  or 
two  unequal  lobes.     It  is  smooth,  hard,  non-fluctuating,  and 


no  DISEASES  G  F  THE  PHARYNX  AND  LARYNX 

very  rarely  pedunculated,  and  adheres  to  the  surfaces  on 
which  it  grows.  It  may  attain  to  the  size  of  a  big  chestnut. 
The  course  is  slow  and  progressive. 

Chondromata  and  myxomata  are  extremely  rare. 

Lipomata  of  the  soft  palate  are  fairly  uncommon.  They 
are  irregular  in  form,  and  are  generally  lobated.  The  con- 
sistency of  a  lipoma  is  soft  and  doughy,  of  a  yellow  hue, 
covered  with  a  fine  pellicle  of  mucous  membrane,  which 
encapsules  it.  It  progresses  very  rapidly  by  acute  attacks, 
and  is  painless. 

Papillomata  almost  alwa3'S  occur  as  greyish  or  rosy- 
grey  tumours  of  cauliflower-like  shape,  joined  by  a  pedicle. 


Fig.  55. — Papilloma  of  the  Extremity  of  the  Uvula. 


either  to  the  uvula  or  at  the  level  of  the  anterior  pillars. 
When  the  papilloma  is  small,  it  very  often  rests  on  the  soft 
palate  or  on  the  uvula,  and  at  first  sight  seems  to  be  a  part 
of  those  structures  ;  but  it  is  easy  with  a  probe  to  make  out 
that  the  tumour  is  pedunculated.  Its  size  varies  from  a 
grain  of  corn  to  an  almond.  Its  development  is  usually 
protracted. 

LIQUID    TUMOURS. 

I.  Angiomata  are  recognizable  by  their  irregular  mam- 
milliform, reddish,  or  dark-red  appearance.  Very  often  they 
are    congenital.      However,    they   occur    accidentally   from 


PATHOLOGY  OF  THE  SOFT  PALATE  m 

unknown  causes.  Their  volume  varies,  as  do  papillomata, 
and  they  can  give  rise  to  grave  haemorrhages. 

True  angiomata,  which  are  recognized  by  movements 
synchronous  with  the  pulse,  are,  fortunate!}-,  very  rare.  The}" 
are  soft  in  consistence,  and  are  sometimes  reducible  by 
pressure. 

2.  Adenomata. — Papillomata  and  adenomata  frequently 
occur.     An  adenoma  appears  as  a  smooth  globular  tumour? 


Fig.  56. — Angioma  of  the  Soft  Palate  and  of  the  Left  Buccal  and 
Lingual  Tonsils.    (Drawn  from  Nature.) 


without  specific  coloration.  To  the  touch  it  resembles  a 
fibroma  or  an  overdistended  cyst.  Its  course  is  slow,  but 
it  may  attain  a  considerable  volume,  without  any  tendency 
to  ulceration. 

3.  Cysts  may  be  recognized  by  their  smooth,  rounded, 
and  sessile  appearance,  being  of  a  rosy-grey  or  pale-yellow 
colour,  and  of  hard  consistency,  varying  in  size  from  a  grain 
of  wheat   to  a   cherry   or  half  a  walnut.     Their    contents 


112  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

are  serous  or  colloid,  and  can  be  easily  removed  by- 
excision. 

4.  Dermoid  cysts  are  rare,  generally  congenital,  and 
attached  to  the  mucous  membrane  by  a  pedicle.  They  have 
usually  the  consistency  of  a  softish  abscess.  On  the  contrary, 
when  they  are  hard  they  may  be  mistaken  for  an  angioma. 
Their  contents  are  characteristic — fat,  muscular  tissue,  and 
cartilage  ;  sometimes  osseous  tissue. 

Prognosis  is  usually  benign.  When  the  cysts  are  removed 
they  have  no  tendency  to  recur.  An  adenoma,  however,  may 
degenerate  into  a  malignant  tumour. 

Diagnosis. — Infiltration  of  the  neighbouring  parts  distin- 
guishes gummata  from  those  tumours. 

Treatment  consists  in  the  removal  of  those  neoplasms. 
Papillomata  should  be  seized  with  the  forceps  and  cut  at  their 
point  of  origin  with  a  bistoury  or  galvano-cautery.  The 
same  may  be  said  of  a  fibroma,  lipoma,  chondroma,  and 
adenoma.  If  the  size  of  the  tumour  is  great,  an  anaesthetic 
should  be  given.  If  the  angioma  is  troublesome,  bipolar 
electrolysis  is  recommended,  or  ligature  of  the  afferent  vessels. 

This  operation  may  be  dangerous  from  the  vascularization 
of  the  parts,  and  of  the  growth  itself. 

Dermoid  cysts,  like  the  adenomata,  should  be  enucleated. 

This  simple  operation  may  be  accomplished  either  with 
cocaine  and  the  use  of  the  frontal  mirror  or  with  chloroform, 
the  patient  being  in  Rose's  posture.  If  haemorrhage  occurs, 
(a  rare  event)  the  carotid  should  be  ligatured. 

If  the  tumour  sends  prolongations  into  the  maxillo- 
pharyngeal  space,  external  methods  should  be  employed. 

MIXED    TUMOURS. 

Those  growths  of  a  heterogeneous  description  originate  in 
the  glandular  recess  of  the  soft  palate,  and  are  surrounded 
and  isolated  by  an  envelope  of  connective  tissue.  According 
to  Berger  those  tumours  consist  of  : 

1.  Epithelial  elements,  recalling  adenoma  or  epithelioma. 

2.  A  reticulation  consisting  of  various  kinds  of  connective 
tissue. 


PATHOLOGY  OF  THE  SOFT  PALATE  113 

This  author  is  of  opinion,  that  those  growths  are  not  of 
endothehal  origin. 

Symptoms. — The  tumours  are  rounded,  frequently  bossed, 
irregular,  and  always  firm  to  the  touch. 

The  mucous  membrane,  with  which  they  are  enveloped,  is 
healthy  and  mobile,  but  frequently  attenuated. 

Those  tumours  are  of  very  slow  growth  (eight  to  ten  years), 
do  not  attack  the  osseous  structure,  and,  although  appearing 
to  be  immobile,  are  non-adherent  to  the  soft  palate. 

Their  symptoms  consist  of  a  more  or  less  well-pronounced 
nasal  intonation,  due  to  the  size  of  the  tumour,  which  may 
ultimately  interfere  with  respiration  and  speech. 

Diagnosis  depends  on  their  origin,  course,  situation,  the 
immunity  of  the  mucous  membrane,  the  mobility  of  the 
tumours,  their  structure,  and  their  yellowish  colour.  The 
sole  difficulty  is  to  differentiate  them  from  sarcoma,  but  the 
latter  is  rare  in  adults,  and  has  a  more  rapid  course.  It  is 
painful,  less  hard  to  the  touch,  and  is  prolonged  into  the 
nasal  fossae,  accessory  cavities,  and  the  parotid  recess.  It 
perforates  and  destroys  the  bony  tissue.  Ulceration  occurs 
and  renders  diagnosis  simple.  We  must  not  forget  that 
similar  encapsuled  sarcomata  also  may  exist.  They  are  of 
slow  growth,  and  non-malignant.  Melanotic  sarcomata  are 
recognizable  chiefly  by  their  dark  colour,  diffuse  form,  rapid 
course,  and  the  functional  complications,  apart  from  the 
glandular,  which  they  produce. 

Treatment  is  fairly  easy,  on  account  of  the  non-infiltration  of 
those  tumours.  If  they  are  small,  chloroforming  the  patient 
in  Rose's  posture,  or  anaesthetizing  the  mucous  membrane 
with  cocaine  (i  to  10)  will  suffice.  Then,  the  jaws  being 
kept  open  by  a  gag,  the  palatine  mucous  membrane  should 
be  cut  from  before  backwards  down  to  and  through  the 
tumour.  Enucleate  with  the  spatula,  the  grooved  probe, 
and  the  finger.  Should  the  growth  be  very  large,  the  pre- 
liminary operation  of  widening  the  means  of  approach  may 
be  performed  by  cutting  the  labial  commissure  on  the  corre- 
sponding side.  If  the  prolongations  of  the  tumour  reach 
the    zygomatic   or  pterygo-maxillary  fossas,   the  enucleation 


114  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

should  be  deep,  and  without  resort  to  external  operation. 
The  bleeding,  which  is  generally  unimportant,  may  be 
stopped  by  efficient  plugging.  If  the  tumours  of  the  soft 
palate  descend  to  the  pharynx,  and  project  below  the  angle 
of  the  jaw,  the  extra-buccal  method  can  be  employed.  An 
incision  is  then  made  in  the  inferior  maxillary  angle,  which 
may  be  resected  if  necessary.  This  method  permits  of  the 
eradication  of  enormous  tumours,  even  of  sarcomata  reaching 
the  palatine  vault.  As  a  whole,  operations  of  mixed  tumours 
on  the  soft  palate  are  usually  easy  to  perform,  and  if  well 
done  prevent  recurrence. 

Calculi  of  the  Soft  Palate. 

Some  interesting  facts  have  been  noted  regarding  calculi 
embedded  in  the  soft  palate  around  the  uvula.  Their  size 
(hazel-nut)  may  produce  disturbances  of  respiration  and  of 
deglutition.  They  are  analogous  to  calcareous  degenerations 
occurring  in  the  tonsils,  and  are  fairly  rare. 

Treatment. — A  longitudinal  incision  with  the  bistoury  or 
galvano-cautery,  sufficient  to  permit  the  passage  of  the 
calculus,  effects  a  cure.  If  the  wound  is  long,  a  few  stitches 
of  catgut  or  horsehair  will  arrest  haemorrhage  and  reunite 
the  lips  of  the  wound. 

Malignant  Tumours. 

Sarcoma  and  Epithelioma  are  the  most  common 
malignant  tumours  on  the  soft  palate  and  the  pillars. 

Etiology. — This  is  somewhat  obscure,  but  it  seems  that 
those  growths  occur  more  frequently  in  men  than  in  women. 
Smoking  appears  to  influence  their  development.  They 
occur  usually  in  middle-aged  patients.  Morbid  degenera- 
tions are  rarer  on  the  soft  palate  than  on  the  tonsils  or  the 
base  of  the  tongue. 

Symptoms. — Functional  symptoms  are  insidious  at  the  be- 
ginning. They  only  appear  when  the  growths  are  sufficiently 
large  to  inconvenience  the  patient.  At  this  stage,  the  soft 
palate  being  more  or  less  immobile,  the  voice  becomes  nasal, 


PATHOLOGY  OF  THE  SOFT  PALATE  115 

and  deglutition  interfered  with  ;  nevertheless,  there  is  no  re- 
gurgitation. Respiration  is  affected  only  when  the  growth  is 
very  large  or  reaches  the  pharynx  and  the  entrance  to  the 
larynx.  Although  the  pains  are  less  intense  than  in  malig- 
nant degeneration  of  the  pharynx,  yet  some  patients  com- 
plain of  pain  on  deglutition  extending  up  to  the  ears. 

True  haemorrhage  is  fairly  rare,  but  blood  may  be  observed 
in  the  expectoration. 

The  general  health  of  the  patient,  slightly  affected  at 
first,  presents  characteristic  modifications  at  the  ulcerative 
stage.  Adenopathy  of  the  neighbouring  parts  only  occurs 
when  the  tumour  has  reached  the  free  edges  of  the  soft 
palate — that  is  to  say,  pillars  and  tonsils. 

Sarcoma  of  the  soft  palate  may  resemble  a  simple  warty 
ulceration,  occupying  its  anterior  surface.  Gradually  the 
reddish  granulations  grow  larger,  invade  the  surroundings, 
and  there  appears  very  soon  above  the  mucous  membrane 
an  easily  recognized  swelling.  It  is  usually  a  myxosarcoma 
which  is  found  m  this  region.  Those  tumours  in  some  cases 
follow  simple  adenoma. 

Epithelioma  usually  appears  as  a  warty  tumour.  Ulcera- 
tion is  generally  rapid,  yet  in  an  exceptional  case  it  may  be 
absent. 

The  Course  of  the  malady  is  usually  progressive,  and  varies 
according  to  the  nature  of  the  tumour  and  the  age  of  the 
patient.  The  sarcoma  of  adolescents  may  be  regarded  as  very 
malignant,  and  its  course  is  rapid  ;  but  in  the  case  of  adults 
and  the  aged  its  development  is  comparatively  slow.  How- 
ever, if  its  course  is  not  checked,  it  progresses  uninterruptedly. 

Diagnosis  between  sarcoma  and  epithelioma  is  difficult, 
and  can  only  be  definitely  ascertained  by  histological 
examination. 

Prognosis  is  extremely  grave  in  all  cases,  for  operations 
apparently  successful  do  not  prevent  a  recurrence.  The 
author  thinks,  that  tumours  of  the  soft  palate  clearly  con- 
fined to  that  organ  and  originating  in  the  central  portion  of 
the  uvula  can  be  radically  cured,  if  operated  on  early. 

Treatment. — The  only  resort  is  surgical  treatment,  which 

8—2 


ii6  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

must  be  as  complete  and  rapidly  executed  as  possible.  To 
be  beneficial  the  operation  should  be  practised  when  the 
growth  is  limited  to  the  central  portion  of  the  soft  palate. 
At  a  later  stage  intervention  tends  to  hasten  the  malady, 
rather  than  to  retard  it. 

Secondary  growths  of  the  tonsils  or  pharynx  cannot  be 
treated  with  success.  When  the  growths  are  confined  to 
the  uvula  and  soft  palate  the  whole  organ  should  unhesitat- 


FiG.'57. — Epithelioma  of  the  Uvula  and  of  the  Soft  Palate. 
(Drawn  from  Nature.) 

ingly 'be]  sacrificed  with  the  thermo-cautery,  which  has  the 
advantage  of  restricting  the  bleeding  to  the  arteries,  and 
simultaneously  cauterizing  the  area  of  the  growth. 

Usually  the  small  arteries  leading  to  the  uvula  bleed 
slightly,  but  it  will  suffice  to  twist  or  ligature  them  to 
prevent  hsemorrhage. 

Palliative  treatment  must  be  resorted  to  when  the 
tumours  are  recurrent,  or  cannot  be  operated  on.  The  best 
method  is  to  administer  strong  arsenical  preparations 
internally,    and    paint    locally   with    tincture   of    thuja,    or 


PATHOLOGY  OF  THE  SOFT  PALATE  117 

tincture  of  celandine,  and  thus  prevent  the  warty  growth  of 
the  tumour  and  the  resultant  respiratory  disturbances.  The 
following  wash  may  be  used  : 

R  Adrenalin  solution  (i  :  100)    ...         5  grammes  ll\^lxxv 

Extract  of  thuja  or  celandine           5          ,,  gr.  75 

Tincture  of  celandine^  _  __|-~v 

Tincture  of  thuja        J           "■                     "  t3v 

Glycerine  (neutral)                    ..         10          „  IT^cxl 

This  mixture  may  be  used  once  or  twice  daily  for  painting, 
and  to  procure  a  satisfactory  result,  it  should  be  thoroughly 
rubbed  in.  A  teaspoonful  in  half  a  glass  of  boiled  water 
may  be  employed  as  a  gargle. 

Swabbing  with  pyoctannin  (i  in  100)  is  beneficial,  but, 
owing  to  its  strong  discoloration  of  the  buccal  mucous 
membrane,  it  is  apt  to  frighten  cancerous  patients. 


Constriction  of  the  Isthmus  of  the  Buccal 
Pharynx. 

The  more  or  less  complete  constriction  of  the  orifice 
between  the  nasal  fossae  and  the  pharynx. 

Etiology. — This  disease  most  frequently  results  from 
syphilis,  but  may  follow  deep  ulceration  of  various  kinds 
of  the  pharyngeal  cavity. 

Symptoms. — The  constriction,  when  not  considerable,  may 
pass  unnoticed,  or  be  accidentally  discovered.  Later  on,  there 
is  interference  of  deglutition,  phonation,  hearing,  and,  above 
all,  respiration. 

Regurgitation  and  nasalization  ('alalie  fermée'  of  Kussmaul) 
are  observed.  Affections  of  the  ear  may  be  due  either  to 
ulcerations  situate  at  the  level  of  the  Eustachian  tube  or  to 
the  constriction  of  the  tube  itself.  Nasal  respiration  gradually 
becomes  impossible  as  the  atresia  advances,  and  the  patient 
is  compelled  to  breathe  by  the  mouth. 

The  appearance  of  the  pharyngeal  cavity  on  examination 
varies,  according  to  the  extension  of  the  ulceration.     The 


ii8 


DISEASES  OF  THE  PHARYNX  AND  LARYNX 


uvula  may  be  drawn  to  the  side,  or  even  replaced  b}'  fibrous 
cicatricial  tissue. 

In  some  cases  the  pharyngeal  wall  is  traversed  by  fibrous 
folds  and  thoroughly  deformed,  the  pillars  becoming  wrinkled, 
the  tonsils  buried  in  the  substance  of  the  new  tissue,  and  the 
soft  palate  frayed  and  anfractuous.  The  morbid  changes 
depend,  of  course,  on  their  cause. 

Pathogeny. — It  has  been  thought  that  the  atresia  was  due  to 
the  contact  of  two  ulcerated  surfaces,  but  the  author  thinks 


Fig.  58. 


-Atresia  of  the  Naso-Pharyxx,  following  Syphilis. 
(Drawn  from  Nature.) 


that  the  naso-pharyngeal  orifice  is  a  true  sphincter,  and  that 
the  constriction  is  from  without  inwards,  the  two  posterior 
pillars  advancing  towards  the  centre.  The  naso-pharyngeal 
circle,  being  more  or  less  infiltrated  and  changed  into  a  cica- 
tricial fibrous  tissue,  gradually  contracts,  so  as  to  obstruct 
the  naso-pharyngeal  cavity. 

The  sole  important  point  in  the  diagnosis  is  to  determine 
the  cause  and  treatment. 

Should  the  naso-pharyngeal  cavity  merely  be  constricted 


PATHOLOGY  OF  THE  SOFT  PALATE 


i\g 


dilate  it  by  a  bougie  introduced  through  the  nasal  fossae. 
Tubes  may  also  be  passed  through  the  mouth  into  the 
naso-pharynx. 

If  the  cavity  is  wholly  obstructed,  make  an  artificial 
opening  as  large  as  possible  mesially,  preferably  with  a 
galvano-cautery,  large  enough  to  admit  a  bougie  of  an  in- 


FiG.  59. — Atresia  of  the  Naso-Pharynx,  following  a  Cicatrized  Lupus. 
(Drawn  from  Nature.) 


creasingly  larger  size.  If  the  patient  is  unable  to  bear  the 
bougie  continuously,  it  may  be  inserted  once  or  twice  daily. 
The  patient  ought  to  learn  the  method  of  its  introduction,  so 
that  he  might  pass  it  himself,  and,  if  need  be,  dilate  further 
the  artificial  opening  thus  made  by  passing  from  time  to 
time  different  bougies  or  suitable  instruments. 


CHAPTER  V 

DISEASES  OF  THE  PHARYNX 

Defects  of  Conformation — Pharyngocele. 

A  MORE  or  less  pronounced  dilatation  of  the  inferior  pharynx. 
If  the  extension  is  confined  to  a  single  point,  a  pocket,  con- 
sisting of  the  submucous  membrane  of  the  wall  covering  the 
muscular  layer,  is  formed,  resembling  a  true  hernia  of  the 
pharynx. 

The  symptoms  of  pharyngocele  are  very  variable,  often  nil, 
but  occasionally  characterized  by  a  sense  of  fulness.  The 
food  may  frequently  return  to  the  mouth,  as  in  rumination. 

The  pockets  may  be  numerous,  and  of  variable  depth. 

Treatment. — The  best  method  of  treatment  consists  in 
closing  up  the  entrance  of  the  pharyngocele  by  inflammatory 
adhesions  ;  but,  unfortunately,  the  inflammation  cannot  be 
controlled — e.g.,  a  perforation  may  occur  which,  if  deep  enough 
to  penetrate  the  neck  or  the  mediastinum,  may  produce  grave 
complications.  The  filling  of  the  cavity  can  be  prevented 
by  external  compression  of  the  neck  with  a  suitable  plate. 
The  author  is  of  opinion  that  the  patients  themselves  should 
empty  the  diverticulum  by  pressure  from  below  upwards. 
If  the  opening  of  the  pharyngocele  were  visible  to  the 
laryngoscope,  atresia  might  be  attempted  by  means  of 
caustic  or  galvanic  applications. 

If  the  life  of  the  patient  is  endangered  the  diverticulum 
should  be  opened  externally,  the  edges  pared  and  brought 
together  as  in  cesophagotomy. 

Wounds. 

Wounds  of  the  pharynx  occur  most  frequently  in  children 
who  injure  themselves  by  putting  articles  in  their  mouths. 

1 20 


DISEASES  OF  THE  PHARYNX  121 

The  wounds  are  extremely  variable,  depending  on  the 
article  used  and  the  mode  of  production.  Radioscopy  enables 
us  to  determine  the  site  and  nature  of  the  traumatism. 

Symptoms. — The  chief  symptom  is  haemorrhage  from  the 
vessels  on  the  pharyngeal  wall.  If  the  blood  cannot  escape, 
it  may  form  a  hsematoma  in  the  submucous  membrane, 
which  is  usually  absorbed  in  situ,  or  may  form  an  abscess. 
Nasalization  and  a  painful  feeling  in  the  neck  on  degluti- 
tion are  complained  of. 

Treatment  consists  at  first  in  arresting  the  haemorrhage  by 
digital  compression,  or  by  plugging  with  wool  or  gauze.  If 
an  important  artery  be  severed,  the  carotid  should  be  liga- 
tured to  prevent  death  from  loss  of  blood.  If  a  detached 
strip  of  mucous  membrane  has  fallen  into  the  larynx,  in- 
cision should  be  effected  by  the  galvano-cautery,  bistoury, 
or  other  suitable  instrument. 


Burns. 

Burns  are  caused  by  swallowing  very  hot  liquids,  or  through 
wilful  or  accidental  introduction  of  caustic  substances  (sul- 
phuric acid,  caustic  potash,  etc.). 

Symptoms. — The  chief  symptom  is  acute  pain  extending 
towards  the  ears.  More  or  less  œdematous  infiltration  is 
produced,  which  interferes  with  respiration.  Sulphuric  acid 
produces  a  brownish  escar,  nitric  acid  a  yellowish,  while 
hydrochloric  gives  a  black  or  deep  red,  and  carbolic  acid 
a  whitish  pellicular  one. 

Diagnosis  is  formed  from  the  history  and  the  appearance  of 
the  lesions. 

Prognosis  varies  according  to  the  depth  of  the  lesions,  and 
the  cicatricial  stenosis,  which  follows. 

Treatment  consists  in  repeated  lavage  of  the  affected  parts 
and  the  application  of  suitable  antidotes,  such  as  milk, 
albumen,  etc. 

The  œsophageal  catheter,  if  used,  must  be  very  gently 
applied,  to  avoid  perforation.     Emollient  gargles  with  coca- 


122  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

leaves,   local    anaesthetics,  and   a   light    diet,   usually  liquid 
or  nearly  so,  should  form  the  basis  of  treatment. 

Vascular  Ectasia  of  the  Pharynx. 

Dilatations  of  the  bloodvessels  are  found  on  the  pharyngeal 
walls.  They  are  generally  submucous  and  deep  enough  not 
to  give  rise  to  haemorrhage. 

On  examination  there  may  be  seen  on  the  lateral  wall 
of  the  pharynx  a  projecting  tumour,  reducible  by  pressure, 
covered  with  healthy  mucous  membrane,  the  pulsation  of 
which  is  isochronous  with  that  of  the  heart. 

At  other  times  sinuous,  slightly  dilated,  and  equally  pulsatile 
vessels  are  seen.  Voluminous  varices  in  the  pharyngeal  wall 
have  also  been  observed. 

Acute  Catarrhal  Pharyngitis. 

An  inflammation  confined  to  the  posterior  pharyngeal 
wall. 

The  usual  causes  are  acute  coryza,  catarrhal  adenoiditis, 
colds,  excessive  use  of  tobacco  or  ardent  spirits. 

The  functional  symptoms  chiefly  consist  in  a  feeling  of 
heat  and  irritation,  specially  on  deglutition,  painful  dysphagia, 
and  acute  pains  reaching  to  the  ear.  If  the  inflammation 
has  affected  the  naso-pharynx,  slight  attacks  of  otitis  media, 
with  its  usual  symptoms — tinnitus,  fulness,  and  deafness — 
are  superadded. 

On  depressing  the  tongue,  there  may  be  seen  on  the 
pharyngeal  wall  redness  and  swelling  of  the  mucosa,  the 
closed  follicles  of  which  project,  causing  a  red  and  granular 
appearance. 

Small  superficial  erosions,  or  even  purulent  formations,  may 
occur,  and  a  slight  œdema  of  the  free  edge  of  the  soft  palate 
and  uvula  may  also  exist. 

By  means  of  the  laryngoscopic  mirror  the  inflammation 
can  be  seen  extending  to  the  oesophageal  orifice. 

Treatment. — Warm  inhalations  should  be  prescribed  and 
intranasal  applications  of  vaseline,  cocainized  or  borated. 


DISEASES  OF  THE  PHARYNX  123 

The  author  generally  employs  this  formula  : 

Ç  gr.  3 
R  Hydrochlorate  of  cocaine    5  to  20  centigrammes      j  . 

(according  to  the  age 
of  patient) 
Powdered  menthol  5  to  15  centigrammes     gr.3tog 

Boracic  acid  ...  i  gramme  gr.  60 

Vaseline     ...  ...  15  grammes  sii 

Take  a  portion  the  size  of  a  pea  and  insert  into  the  nostril 
twice  or  thrice  daily.  This  should  be  sniffed,  so  that  it  may 
reach  the  naso-pharynx. 

Borated  alkaline  gargles,  and  especially  painting  of  the 
inflamed  wall  with  zinc  chloride  (i  in  30),  are  excellent  methods 
to  check  the  affection.  If  small  abscesses  appear  they  should 
be  opened  with  the  galvano-cautery  or  the  probe. 

Thrush. 

Although  thrush  is  a  secondary  disease  chiefly  occurring 
in  children  and  associated  with  disturbances  of  digestion,  it 
may  exist  independently  on  the  posterior  wall  of  the  buccal 
and  inferior  pharynx.  It  occurs  more  rarely  in  adults — 
e.g.,  in  advanced  tuberculosis. 

Locally  the  patient  complains  of  a  feeling  of  dryness  or 
even  of  heat  in  the  pharynx. 

On  examination,  white  milky  spots  {Oïdium  albicans)  are 
observed  projecting  above  the  mucous  membrane.  If  the 
eruption  is  somewhat  older,  the  spots  are  yellowish,  re- 
sembling cream,  on  a  reddish,  but  not  swollen,  background. 
Thrush,  fairly  adhesive  at  first,  is  easily  detached  about 
twenty- four  or  forty-eight  hours  after  its  appearance. 

The  treatment  prescribed  should  be  an  alkaline  diet  (eggs, 
milk,  eau  de  Vichy),  excluding  soups  and  meats  for  two  or 
three  months. 

Alkaline  gargles  and  washes  cause  the  thrush  to  disappear 
rapidly. 


124  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

Gangrene  of  the  Pharyngeal  Cavity. 

This  is  sometimes  localized  in  the  pharyngeal  wall,  but  it 
most  frequently  invades  simultaneously  the  soft  palate  and  the 
tonsils.  It  is  generally  seen  in  children,  but  also  occurs  in 
youths  and  adults.  Usually  it  supervenes  as  a  complication 
of  infectious  anginse,  due  to  scarlatina,  measles,  small-pox, 
typhoid  fever,  or  diphtheria,  etc. 

Debilitated,  underfed  subjects  are  most  frequently  attacked. 

Symptoms. — The  general  symptoms  are  sometimes  suffi- 
ciently grave  to  attract  the  attention  of  the  patient  and 
practitioner.  The  onset  may  be  sudden,  characterized  by 
shivering,  fever,  and  pain  in  the  pharynx.  Sometimes,  how- 
ever, the  affection  may  be  ushered  in  by  general  fatigue  and 
by  a  train  of  symptoms  resembling  those  of  the  onset  of 
typhoid  fever.  At  a  later  stage  petechias,  foetid  diarrhoea, 
with  or  without  haemorrhage,  indicate  the  general  infection 
of  the  subject. 

Functionally,  there  occur  fetor  of  breath,  sanious  or  muco- 
purulent expectoration,  often  with  patches  of  gangrenous 
mucous  membrane. 

Deglutition  is  painful,  to  such  an  extent  that  certain 
patients  refuse  to  take  food.  Regurgitation  may  occur  at 
the  beginning. 

Examination  reveals  at  first  redness  of  the  pillars,  tonsils, 
and  posterior  wall  of  the  pharynx,  accompanied  by  slight 
swelling.  Soon  afterwards  a  series  of  greyish  rounded  or 
irregular-edged  patches  are  seen,  of  a  size  varying  from  a  pea 
to  a  sixpence.  The  edges  of  those  ulcerations  are  irregular 
and  clean-cut  at  the  expense  of  the  mucous  membrane,  which 
is  red,  infiltrated,  and  sometimes  even  spotted  with  small 
phlyctenulse  which  emit  a  fetid  sanious  detritus. 

Subsequently  the  whole  pharyngeal  cavity  is  turned  into 
an  extensive  ulcer.  The  semi-detached  uvula  hangs  in  the 
pharynx  covered  with  a  thick  diphtheroid  membrane  ;  the 
pillars,  the  posterior  wall  of  the  pharynx,  are  transformed 
into  a  greyish,  shapeless  mass,  in  the  midst  of  which  it  is 
difficult  to  recognize  the  various  structures. 


DISEASES  OF  THE  PHARYNX  [  125 

From  time  to  time  portions  of  sphacelated  membrane  are 
detached  and  expectorated  by  the  patient  with  more  or  less 
effort,  and  sometimes  accompanied  by  bleeding  serious  enough 
to  endanger  life. 

Albuminuria  is  frequent.  The  course  of  the  disease  is 
generally  slow,  but  progressive.  Prostration  gradually  in- 
creases. Fever  may  disappear  and  the  pulse  become  weak. 
The  extremities  get  cold  and  the  temperature  falls.  Profuse 
perspiration  and  haemorrhage  follow,  and  the  patient  gradually 
succumbs.     In  some  very  rare  cases  recovery  takes  place. 

According  to  Trousseau,  the  affection  may  endure  from 
eight  to  fourteen  days.  The  author,  however,  has  seen  it 
persist  for  several  months. 

Complications. — The  most  frequent  are  remote  haemorrhage 
(lungs  and  viscera  rarely),  oedema  of  the  surrounding  parts, 
particularly  the  infiltration  of  the  aryepiglottic  folds,  with  its 
attendant  respiratory  disturbances. 

Prognosis  is  very  grave,  and  the  disease  generally  terminates 
fatally,  only  about  2  per  cent,  recovering. 

Diagnosis. — Gangrene  of  the  pharynx  can  only  be  confused 
with  diphtheria,  but  in  the  grave  forms  of  the  latter  the  false 
membranes  are  generally  whiter,  and  show  characteristic 
glandular  involvement.  Apart  from  bacteriological  examina- 
tion, the  course  of  the  disease,  the  absence  of  sphacelated 
spots  and  of  fetid  breath  would  suffice  to  determine  the 
diagnosis.  However,  it  must  be  remembered,  that  gangrene 
has  sometimes  been  a  sequel  and  complication  of  diphtheria. 
In  those  cases  the  diagnosis  may  be  assured  by  the  appearance 
of  the  symptoms  already  indicated. 

Treatment. — In  presence  of  so  grave  a  disease,  immediate 
and  energetic  means  should  be  taken.  The  primary  object 
is  to  maintain  the  strength  of  the  patient  by  means  of  a 
general  tonic  treatment  (quinine  and  champagne).  Caco- 
dylate  of  soda  can  be  administered,  either  internally  or  as 
a  hypodermic  injection,  along  with  injections  of  serum, 
or  caffeine,  etc. 

Locally  the  best  antiseptics  should  be  employed,  according 
to  the  following  method  : 


126  DISEASES  OF  THE  PHARYXX  AXD  LARYXX 

Regular  and  frequent  bathing  of  the  throat  with  alkahne 
washes  or  a  solution  of  hydroxyl  ;  antiseptic  but  not  caustic 
sprays  (carbolic  acid,  hydrochloric  acid,  thymol,  salicylic  acid, 
etc.j  are  also  advantageous.  From  time  to  time  the  affected 
parts  should  be  painted  with  lemon-juice,  carbolized  glycerine 
d  in  5  or  I  in  3),  or  even  with  solution  of  zinc  chloride  (i  in  30 
or  even  i  m  15). 

The  practitioner  must  be  ver}'  careful  not  to  cut  with  the 
bistoury  or  the  forceps  the  shreds  of  mucous  membrane 
which  are  not  yet  sphacelated,  as  death  from  hsemorrhage 
might  ensue.  If  cedematous  complications  occur  in  the 
larynx,  intubation  or  tracheotomy  can  be  resorted  to. 


Pharyngitis  Sicca. 

A  chronic  inflammation  of  the  mucous  membrane  of  the 
phar}-nx  characterized  by  dryness,  with  or  without  atrophy 
of  the  membrane. 

Etiology.  —  Dryness  of  the  pharyngeal  cavity  has  been 
described  as  symptomatic  of  some  affections  of  the  nasal 
fossae  (hypertrophy  of  the  turbinated  bodies,  adenoid  growths, 
and  abnormalities  of  the  septum,  etc.j.  This  may  also  be 
seen  in  certain  general  affections  (granular  pharyngitis, 
cardiac  affections,  diabetes,  or  Bright's  disease). 

It  may  often  have  an  independent  existence.  Two  forms 
are  recognized — chronic  catarrh  of  the  pharyngeal  tonsil 
and  a  true  atrophic  pharyngitis. 

The  former  is  a  true  scrofulide,  and  follows  catarrh  of 
the  nasal  fossae  and  often  of  the  naso-pharynx.  It  frequently 
occurs  in  children  affected  \\-ith  adenoid  growths  and  of 
Ivmphatic  or  even  strumous  appearance. 

The  latter  may  be  attributed  to  the  too  rapid  passage  of 
the  air  into  excessively  broad  nasal  fossa,  but  usually  is  due 
to  the  slow  but  progressive  atrophic  process  extending  from 
the  nose  to  the  pharyngeal  mucous  membrane. 

Symptoms. — In  chronic  catarrh  no  marked  dryness  of  the 
pharynx  appears.  The  patient  expectorates,  especially  in 
the    mornmg,    a    thick,    yellowish,    viscous    secretion,    often 


DISEASES  OF  THE  PHARYNX  127 

crusted  and  having  the  characteristic  odour  of  an  ozgenal 
catarrh.  Sometimes  it  may  appear  more  mucopurulent 
than  dry.  On  examination  after  removal  of  this  secretion, 
the  mucous  membrane  appears  reddish  and  shagreened, 
swollen  here  and  there  rather  than  atrophied,  and  occa- 
sionally pale  and  discoloured. 

Rhinoscopy  reveals  the  extension  of  the  catarrh  to  the 
naso-pharynx,  which  latter  is  often  affected  with  adenoiditis. 

In  this  particular  form  of  dry  pharyngitis  neither  ozsena 
nor  atrophy  of  the  turbinated  bodies  is  present,  and  it  seems 
to  be  a  prelupic  catarrh. 

In  atrophic  pharyngitis  the  act  of  deglutition  is  trouble- 
some, and  the  pharynx  is  intensely  dry.  If  the  larynx  is 
affected  the  expectorations  are  thick,  viscous,  even  crusted. 
The  naso-pharynx  and  the  pharynx  itself  are  lined  with 
greenish  crusts.  Should  the  naso-pharynx  be  involved,  hear- 
ing is  interfered  with  (deafness,  tinnitus,  etc.)  from  catarrh 
of  the  tube. 

A  marked  widening  of  the  pharynx  is  seen,  the  mucous 
membrane  being  dry,  as  if  covered  with  thick  varnish,  trans- 
parent here  and  there.  Below  this  coating  the  membrane 
is  wrinkled  and  attenuated,  and  is  often  pale  and  discoloured. 

Diagnosis. — When  an  adult  merely  complains  of  dryness 
of  the  throat,  and  examination  reveals  the  presence  of  a  dark- 
red  coloration  with  thickening  of  the  palatal  mucous  mem- 
brane, the  pillars,  and  the  pharynx,  the  glistening  look  may 
suggest  diabetes  or  albuminuria.  If  those  semisolid  or  muco- 
purulent masses  are  observed  on  the  posterior  wall  in  children 
or  youths,  the  nasal  fossse  and  the  posterior  nares  should 
be  examined  to  determine  if  there  exists  at  this  level  a  cause 
sufficient  to  produce  the  pharyngeal  catarrh. 

If  traces  of  pus  are  present  on  the  lateral  walls,  or  only  on 
one  side,  they  may  indicate  sinus  affection,  and  the  origin  of 
the  pharyngitis  may  be  found  there. 

Treatment. — In  chronic  catarrh  of  the  pharyngeal  tonsil 
tonic  treatment  is  indicated  (cod-liver  oil,  arsenic,  sulphurous 
waters,  etc.). 

Locally,  curetting   of  the  naso-pharyngeal    cavity  is    the 


128  DISEASES  OF  THE  PHARYNX  AXD  LARYNX 

best  method  of  rapidly  reducing  the  inflammatory  process. 
In  other  cases  painting,  nasal  washes,  or  even  nasal  massage, 
should  be  resorted  to. 

In  the  atrophic  form  the  general  treatment  consists  in  the 
administration  of  the  iodide  of  potassium  or  sodium  or  benzo- 
ate  of  soda  internally.  A  course  of  mineral-water  treatment 
should  prove  beneficial  to  the  patient. 

Locally,  nasal  washes  may  be  prescribed,  with  salt  water, 
biborate  of  soda,  or  boracic'  acid  (2  teaspoonfuls  in  a  litre 
of  tepid  water j. 

Painting  or  spraying  with  an  oily  mentholated  solution, 
according  to  the  following  formula,  is  recommended  : 

li  Eucalyptus     ...  25  centigrammes  iTLiv 

Thymol           ...  5  to  15  centigrammes  gr.  i  to  3 

Menthol           ...  2  to  4  grammes  gr.  30  to  60 

Liquid  vaseline  100  grammes  5i.v 

Vibratory  massage  will  afford  relief. 

Retro-pharyngeal  Abscesses. 

These  abscesses,  circumscribed  at  first,  are  situate  in  the 
cellular  tissue  surrounding  the  pharynx. 

Etiology,  etc. — The  pharynx  in  its  upper  portion  is,  as  it 
may  be  recalled,  gutter-shaped,  opening  anteriorly,  and  forms 
on  its  under  side  a  complete  canal.  It  may,  therefore,  be 
inferred  that  abscesses  of  the  buccal  and  nasal  regions  are  at 
the  same  time  retro-pharyngeal  and  lateral,  while  those 
situate  inferiorly  are  sometimes  mesial.  There  are  two 
chief  forms  of  abscesses  in  this  region — viz.,  (i)  acute 
inflammatory,  and  (2)  chronic  inflammatory  (cold  abscess). 

The  latter  are  usually  of  tubercular  origin,  and  are  fre- 
quently indicative  of  Pott's  disease,  or  of  a  general  affection. 

Behind  the  phar3-nx  and  oesophagus  a  species  of  cavity 
exists,  bounded  posteriorly  by  the  prevertebral  aponeurosis, 
and  anteriorly  by  a  cellular  space,  which  facilitates  the 
movement  of  those  organs. 

On  each  side  is  seen  the  sagittate  follicle  of  Charpy.  The 
cavitv   is   liable    to    become   distended   bv  air   or   fluid,   and 


DISEASES  OF  THE   PHARYNX  129 

extends  from  the  base  of  the  skull  to  the  mediastinum.  At 
the  level  of  the  naso-pharynx  it  is  divided  longitudinally  into 
two  secondary  cavities. 

Inside  the  cavity,  in  the  middle  of  the  cellular  tissue,  lie 
on  each  side  the  superior  ganglia  of  the  sympathetic,  and  the 
lymphatic  glands  of  Gillette. 

The  retro-pharyngeal  glands  receive  the  lymphatic  vessels 
from  the  nose,  the  Eustachian  tube,  the  naso-pharynx, 
and  the  pharynx.  Those  organs  are  usually  the  seat  in 
which  retro-pharyngeal  infection  starts.  Acute  abscesses  of 
the  pharynx  are  fairly  rare,  occurring  frequently  in  children, 
and  sometimes  in  adults.  Lymphatic  temperament,  debility, 
and  bad  hygienic  conditions,  all  conduce  to  this  pyogenic 
lesion.  In  some  cases  the  disease  is  a  sequel  of  an  eruptive 
fever,  influenza,  acute  bronchitis,  purulent  coryza,  acute 
adenoiditis,  or  suppurative  otitis  media. 

Pathological  Anatomy. — The  pus  is  situate  in  the  naso- 
pharynx, buccal  pharynx,  or  inferior  pharynx.  The  abscess 
is  usually  unilateral  at  its  commencement.  The  pus  is 
generally  fetid,  viscid,  and  yellowish,  but  it  contains  no 
specific  organism. 

The  symptoms  at  first  are  sometimes  those  of  a  mere 
angina  or  acute  coryza.  At  other  times,  and  especially  in 
children,  the  onset  passes  unperceived.  In  the  case  of 
unweaned  infants,  lack  of  appetite  and  respiratory  difficulties 
are  observed.  Fever,  accompanied  by  shivering  and  nausea, 
convulsions,  and  general  dejection,  appear  soon  after.  The 
least  movement  of  the  head  is  painful.  The  troubles  of 
deglutition  increase,  and  are  complicated  by  regurgitation. 
Respiration  is  interfered  with.  Then  dyspnoea  and  stridor 
supervene,  accompanied  with  croup-like  suffocative  spasms. 
Those  symptoms  are  due  to  the  peripheral  infiltration,  which 
often  extends  to  the  laryngeal  orifice,  or  immobilizes  the 
crico-arytenoid  articulation  on  the  affected  side.  The  voice 
remains  normal,  with  a  slight  nasal  timbre. 

In  adults  functional  troubles  are  more  easily  observed,  are 
less  pronounced,  and  are  mainly  confined  to  difficulties  of 
deglutition. 

9 


I30  DISEASES  OF  THE  PHARYXX  AND  LARYNX 

Externally,  if  the  abscess  is  mesial,  the  neck  is  stiff,  but  not 
swollen  ;  if  lateral,  there  appears  behind  the  angle  of  the  jaw 
a  swelling,  accompanied  by  adenitis,  and  painful  to  the  touch. 
At  a  later  stage,  if  the  pus  extends  beyond  the  pharyngeal 
aponeurosis,  the  signs  of  latero-pharyngeal  abscess  are 
observed. 

An  examination  of  the  throat,  which  is  rather  difficult 
in  the  case  of  children,  shows  a  red  infiltrated  pharyngeal 
wall,  projecting  towards  the  buccal  cavity  up  to  the  soft 
palate.  On  laryngoscopic  examination,  it  is  observed  that 
the  swelling  extends  backwards  to  the  entrance  of  the 
œsophagus,  or  to  the  posterior  wall  of  the  larynx. 

The  soft  palate  and  the  tonsils  are  usually  unaffected,  or 
simply  pushed  forward. 

Fluctuation  is  perceived  by  the  touch. 

External,  combined  with  pharyngeal,  palpation  reveals  the 
presence  of  a  large  purulent  accumulation,  extending  beyond 
the  pharyngeal  wall. 

Œdema  of  the  neighbouring  structures  is  observed  almost 
entirely  in  inferior  or  diffuse  retro-pharyngeal  abscesses,  and 
then  occupies  the  aryepiglottic  folds  or  the  arytenoid  region. 

Course. — In  the  case  of  inflammatory  abscesses  the  course 
is  generally  rapid.  In  four  or  five  days  pus  accumulates, 
usually  more  rapidly  in  median  retro-pharyngeal  cases  than 
in  the  lateral. 

At  other  times  suppuration  takes  place  b}-  successive 
exacerbations,  lasting  for  weeks  or  months,  or  even  becoming 
chronic. 

The  author  has  seen  adult  cases  without  finding  any  osseous 
lesions.  In  those  cases  the  local  and  general  symptoms  are 
much  less  pronounced,  whereas  deglutitional  disturbances 
predominate. 

Prognosis. — If  the  abscess  is  left  to  itself  it  ma}-,  although 
very  seldom,  open  spontaneously,  and  then  the  pus  escaping 
into  the  pharynx  and  the  larynx  may  cause  death,  which 
happens  frequently  in  children. 

Asphyxia  may  also  result  from  the  respiration  being  impeded 
through  œdema.     During  the  later  stages  grave  haemorrhages. 


DISEASES  OF  THE  PHARYNX  131 

due  to  ulceration  of  a  large  vessel,  may  occur,  with  fatal 
results. 

Diagnosis  is  easy,  when  the  abscess  is  developed,  but  at  its 
outset  in  children  it  may  be  mistaken  for  the  various  inflam- 
matory lesions,  including  diphtheria.     The  introduction  of  a 


mpv 


e  -rp 


Fig.  60. — Diagrammatic  Horizontal  Section  of  the  Normal 
Retro-pharyngeal  Space.     (Escat.) 

For  the  sake  of  distinctness  we  have  coloured  the  principal  organs  of  the 
region. 

Explanation  of  the  diagram:  vc,  Cervical  vertebra  ;,  ï^f ,  vertebral  foramen; 
av,  vertebral  artery,  accompanied  by  the  vein  in  blue  ;  mpv,  prevertebral 
muscles  ;  gyp,  retro-pharyngeal  ganglion  ;  erp.  retro-pharyngeal  space  ; 
app,  prevertebral  aponeurosis  ;  tf,  fibrous  coat  of  the  pharynx  ;  apl,  lateral 
aponeurosis;  pg,  pneumogastric  ;  7,  jugular;  c,  carotid;  glp,  latero- 
pharyngeal  ganglion. 

foreign  body  into  the  pharynx  is  usually  accompanied  by 
suffocative  spasm,  but  direct  examination  will  determine  the 
cause. 

Adenoiditis  is  characterized  by  disturbances  of  nasal 
respiration,  pains  in  the  ears,  an  intact  pharyngeal  wall,  with 
absence  of  troubles  in  deglutition.     The  usual  position   of 


DISEASES  OF  THE  PHARYNX  AND  LARYNX 


the  neck  will  be  of  valuable  assistance  in  diagnosing  Pott's 
disease  or  ostitis.  In  adults  it  might  be  confounded  with 
a  gummatous  infiltration  of  the  pharyngeal  wall,  but  in  the 
latter  the  swelling  is  almost  painless,  characteristically  hard, 
confined  to  the  lateral  portion  of  the  pharynx,  is  fairly  circum- 
scribed, and  very  soon  shows  on  its  surface  a  characteristic 
crateriform  ulceration. 


ntpx) 


■0rp 
P9 


Fig.  6i. — Diagrammatic  Horizontal  Section  showing  the  Modifica- 
tions OF  THE  ReTRO-PHARYNGEAL  SpACE   IN  THE   LATERAL   ABSCESS  OF 

THIS  Region. 

The  explanation  of  the  diagram  is  the  same  as  in  Fig.  60  ;  the  difference 
consists  in  the  projection  forwards  of  the  fibrous  coat  of  the  pharynx 
which  juts  out.  The  dotted  Unes  indicate  the  tract  by  which  the  pus 
arrives  at  the  latero-pharyngeal  space.  The  vasculo-nervous  bundle  is 
pushed  outwards. 

Chronic  abscesses  are  recognizable  by  their  slow  course 
and  by  the  presence  of  fluctuation. 

Suppurative  adenitis  is  accompanied  by  external  symptoms 
so  characteristic  as  to  preclude  any  doubt  of  their  nature. 

The  diagnosis  consists  in  differentiating  between  retro- 
pharyngeal abscesses  and  the  purulent  collections  in  the 
external  wall  of  the  tonsillar  crypt,  or  in  the  latero-pharyngeal 
region. 


DISEASES  OF  THE  PHARYNX  133 

A.  When  the  disease  originates  in  the  retro-pharyngeal 
gland  (posterior  and  lateral  abscess)  the  retro-pharyngeal 
aponeurosis  is  pushed  forward,  while  the  lateral  fibrous 
plane  is  thrust  outwards.  Often  the  affection  extends  through 
this  wall  to  the  latero-pharyngeal  recess,  where  it  produces 
adenitis. 

B.  In  other  cases,  the  infection  originating  in  the  posterior 
wall  extends  rapidly,   probably  through  the  lymphatics,  to 


ctpl 


Fig.  62. — Diagrammatic  Horizontal  Section,  showing  the  Modifica- 
tions OF  THE  Latero-pharyngeal  Region  in  Abscesses  situate  out- 
side THE  Lateral  Aponeurosis  of  the  Pharynx,  aj>I.     {Cf.  Fig.  54.) 

The  posterior  fibrous  wall  tf  is  normal,  but  the  dotted  lateral  aponeurosis  to 
the  right  of  the  figure  is  crowded  inwards,  pushing  in  front  of  it  the  tonsil, 
and  causing  a  marked  swelling  on  the  lateral  side  of  the  neck. 

the  tissues  situate  outside  the  lateral  aponeurosis.  Simple 
retro-pharyngeal  adenitis  then  occurs,  and  pus  collects  in 
the  latero-pharyngeal  region,  pushing  inwards  the  intervening 
wall.  In  those  cases  the  lesion  is  outside  the  pharynx,  and 
the  peripheral  swelling  takes  place  outwards,  the  reverse 
being  noticed  in  the  preceding  case. 


34 


DISEASES  OF  THE  PHARYNX  AND  LARYNX 


C.  External  peritonsillar  abscess  is  also  seated  inside  the 
lateral  aponeurosis  of  the  pharynx,  which  it  pushes  outwards, 
and  the  pus — at  least,  at  the  outset — is  inside,  but  the  latero- 
pharyngeal  portion  is  swollen  and  projects  outwards.  The 
diagrams  will  indicate  how  the  rupture  of  the  over-tense  and 
affected    lateral    aponeurosis    may    change    a    simple    retro- 


app 


////-. CLpL 

U'l tf 


Fio.  63. — Diagrammatic  Horizontal  Section,  showing  the  External 
Region  of  the  Left  Tonsil  (a)  in  the  Case  of  Abscess  originating 
FROM  THIS  Part  of  the  Tonsillar  Recess.  (Right  Sii'E  of  the 
Figure.) 

The  fibrous  coat  of  the  base  of  the  dotted  crypt  tf  blends  with  the  lateral 
aponeurosis  apl,  while  the  vasculo-nervous  bundle  is  pushed  outwards 
and  backwards.  If  the  lateral  wall  ruptures,  the  pus  then  forms  the 
latero-pharyngeal  phlegmon  ;  if  it  resists,  the  pus  penetrates  into  the 
mouth  around  the  tonsil.     This  is  usually  the  case. 


pharyngeal  abscess  into  an  external  peritonsillar  or  a  deep 
and  diffuse  phlegmon  of  the  neck,  or  latero-pharyngeal 
abscess.  In  this  way  grave  vascular  lesions  and  their  severe 
complications  are  explained. 

Treatment. — At    first  we  should    endeavour  to   check    the 


DISEASES  OF  THE  PHARYNX  135 

abscess  by  warm  inhalations,  by  compresses  applied  to  the 
anterior  part  of  the  neck,  and  by  a  purgative.  But  if  the 
diagnosis  points  to  an  abscess,  incision  should  be  made  as 
earl}^  as  possible. 

A  bistoury,  failing  a  more  suitable  instrument,  is  wrapped 
round  with  diachylon,  or  even  paper,  so  that  its  point  alone  is 
uncovered.  The  patient's  mouth  being  kept  open,  and  the 
tongue  depressed  behind  the  dental  arch,  an  incision  is  made 
at  its  most  prominent  part.  With  intractable  children  a  few 
whiffs  of  ethyl  bromide  or  somnoform  will  facilitate  the 
operation. 

On  the  evening  of  the  operation,  or  the  day  after,  it  may 
be  necessary  to  keep  the  edges  of  the  wound  open  to  aid  the 
escape  of  pus.  In  adults  a  i  in  10  solution  of  cocaine  with 
adrenalin  will  produce  complete  anaesthesia. 

The  author  prefers  to  use  the  galvano-cauter}-,  as  it  admits 
of  the  affected  parts  being  widely  opened,  and  remaining  so 
long  enough  to  enable  the  pus  to  escape. 

Often  when  the  abscess  is  opened,  in  the  case  of  debilitated 
patients,  syncope  or  even  death  supervenes.  As  there  is  a 
considerable  amount  of  pus  in  the  abscess,  even  when  it 
appears  small,  it  will  be  advisable  to  tap  it,  so  as  to  permit 
the  pus  to  escape  gradually,  and  thus  prevent  its  irruption 
into  the  air  passage. 

Antiseptic  washing  of  the  mouth  and  pharyngeal  wall 
(hydroxyl  in  boiled  water,  Vichy  water,  boiled  borated  water) 
should  be  carefully  performed  by  the  medical  attendant,  till 
the  patient  is  completely  cured.  If  the  pharyngeal  abscess 
is  complicated  by  inflammation  of  the  cellular  tissue  of  the 
neck  and  by  external  swelling,  it  would  be  better  to  reach 
the  abscess  externally.  An  abscess  impossible  to  open  through 
the  mouth  may  thus  be  thoroughly  drained.  The  opening 
should  be  made  at  the  anterior,  or  preferably  at  the  posterior, 
edge  of  the  sterno-mastoid.  The  incision  should  be  methodi- 
cally performed  layer  by  layer  with  good  illumination  and 
with  the  grooved  probe.  A  drainage-tube  should  then  be 
placed  in  the  wound,  and  kept  there,  until  the  fistulous 
opening  is  completely  cured  from  below  upwards. 


136  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

Chronic  Pharyngitis. 

Synonyms.  —  Granular  angina,  hypertrophic  granular 
pharyngitis. 

Granular  pharyngitis  has  in  recent  years  lost  much  of  its 
importance,  owing  to  our  better  knowledge  of  diseases  of  the 
throat.  Generally  speaking,  those  projecting  ovular  granu- 
lations, resembling  split  peas,  adhering  to  the  posterior  wall 
of  the  pharynx,  are  the  necessary  symptoms  of  chronic 
inflammation  of  the  pharyngeal  cavity,  rather  than  the  cause 
of  the  troubles  of  which  the  patient  complains. 

Etiology. — Those  granulations  of  the  pharynx  often  met 
with  in  children  may  be  regarded  as  the  terminal  portion  of 
Luschka's  tonsil.  They  are  merely  the  symptoms  of  a  more 
important  lesion.  True  granular  pharyngitis  is  frequent, 
especially  in  youths  and  adults,  particularly  in  those  who 
make  an  exaggerated  use  of  their  voice,  or  are  exposed,  by 
profession  or  by  habit,  to  irritation  of  the  throat. 

Symptoms. — In  children  hypertrophy  of  the  closed  follicles 
of  the  pharyngeal  cavity  coincides  almost  always  with  a 
swelling  of  the  pharyngeal  tonsil. 

Other  symptoms  are  a  feeling  of  malaise  in  the  pharynx 
and  a  tickling  and  burning  sensation,  which  causes  the 
patient  to  hem,  especially  in  the  morning.  The  feeling  of 
constriction  and  of  a  foreign  body  in  the  throat  may  be  due 
to  neurasthenia,  rather  than  to  chronic  inflammation  of  the 
closed  follicles  of  the  pharynx. 

Functional  symptoms  are  observed  only  at  the  time  of 
acute  or  subacute  onsets,  and  vary  according  to  the  nature 
and  degree  of  the  inflammation.  In  some  cases  pain  is 
felt  extending  up  to  the  ear.  Those  troubles  are  more  pro- 
nounced in  chronic  hypertrophy  of  the  lingual  tonsil,  on 
account  of  the  friction  of  the  latter  on  the  epiglottis,  or  when 
the  hypertrophy  is  seated  in  the  dihedral  angle  formed  by  the 
base  of  the  tongue  and  the  origin  of  the  anterior  pillar. 

Readily  occurring  congestion  of  the  larynx  with  huskiness 
complete  the  symptoms  of  granular  pharyngitis.  Objectively 
two  forms  are  met  with.     In  the  one,  called  exudative  (Sir 


DISEASES  OF  THE  PHARYNX  137 

Morell  Mackenzie),  the  mucous  membrane  is  smooth  and 
even,  reddish,  and  here  and  there  swollen.  The  vessels  are 
dilated  and  sinuous.  The  pharyngeal  wall  is  covered  with 
a  greyish  very  adhesive  mucus.  This  secretion  is  seen  in 
the  naso-pharynx,  as  this  disease  is  usually  accompanied 
with  chronic  adenoiditis.  In  the  other  form  there  may  be 
seen  on  the  posterior  wall  of  the  pharynx  reddish,  more  or 
less  confluent  granulations,  adherent  to  the  mucous  mem- 
brane. In  chronic  forms  they  appear  as  projecting,  irregular 
ridges,  situate,  as  a  rule,  behind  the  posterior  pillars. 

Each  granulation  is  surrounded  by  a  vascular  network, 
which  sharply  defines  it.  The  glands  of  the  mucous  mem- 
brane are  themselves  often  inflamed  and  covered  over  with 
a  whitish,  viscous  secretion,  which  must  be  removed  to 
disclose  the  pharyngeal  wall. 

Diagnosis  is  generally  easy,  but  we  must  be  careful  not  to 
confuse  secondary  hypertrophy  of  the  closed  follicles  of  the 
pharyngeal  cavity  with  cases  fairly  rare,  where  this  chronic 
inflammation  is  a  true  morbid  entity.  The  nasal  fossae,  the 
posterior  nares,  the  accessory  cavities  of  the  throat,  and  the 
base  of  the  tongue  should  be  carefully  examined,  in  order  to 
exclude  all  concomitant  lesions,  capable  of  causing  chronic 
hypertrophic  folliculitis  of  the  pharynx. 

Care  must  be  exercised  not  to  assign  to  granular  pharyn- 
gitis the  whole  series  of  nerve  disturbances  inevitably  asso- 
ciated with  neurasthenia.  These  different  nervous  troubles 
abate  at  the  time  of  deglutition,  whereas  true  inflammatory 
affections  are  then  increased. 

The  prognosis  is  grave  only  when  laryngeal  or  auricular 
complications  occur. 

Pathological  Anatomy. — The  changes  are  seen  chiefly  at 
the  level  of  the  lymphoid  tissue  of  the  muciparous  glands 
and  the  connective  stroma  of  the  mucous  membrane. 

Treatment  should  be  directed  to  the  sources  of  the  disease — 
the  nasal  fossae,  pharyngeal  cavity,  or  base  of  the  tongue. 
If  the  folliculitis  requires  a  special  treatment,  the  simplest 
method  is,  either  to  curette  the  granulations  or  paint  them 
with  an  aqueous  solution  of  iodide  of  potassium  (i  in  5).     At 


30 

gr.5 

3  grammes 

Ri 

5 

ni^lxxx 

120 

oiiiss 

138  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

other  times  galvanic  ignipuncture  should  be  employed  ;  but 
the  cauterization  must  not  be  too  deep,  as  it  might  harm 
the  patient  more  than  the  granulations  do.  General  treat- 
ment may  have  good  results,  and  a  course  of  mineral  waters 
(sulphurous,  arsenical,  or  alkaline)  will  be  advantageous.  In 
benign  cases  alkaline  bathing  of  the  throat,  according  to  this 
formula,  will  suffice  : 

li  Iodine  ...  ...  ...     25  centigrammes    gr.  4 

Iodide  of  potassium  ... 
Tincture  of  opium  (Sydenham) 
Tincture  of  guaiacum 
Glycerine  (pure) 

A  teaspoonful  in  half  a  glass  of  tepid  water  as  a  gargle,  once 
or  twice  a  day,  or  undiluted  painting  once  or  twice  weekly. 

Foreign  Bodies  in  the  Pharyngeal  Cavity. 

Etiology.  —  Insensibility  of  the  mucous  membrane  or 
paralj^sis  of  the  constrictor  may  favour  the  retention  in  the 
throat  of  bodies  of  various  natures  and  sizes. 

Symptoms. — -The  chief  foreign  bodies  are  fish-bones,  pins, 
cherry-stones,  etc.,  and  the  symptoms  vary  according  to  the 
form,  nature,  and  seat  of  the  object.  There  is  either  an 
onset  of  choking  or  a  sensation  of  very  acute  pain,  becoming 
more  pronounced  at  every  movement  of  the  neck,  or  a  desire 
to  expectorate  or  vomit.  Radioscopy  may  be  of  good  assis- 
tance, when  simple  inspection  of  the  throat  by  the  tongue- 
depressor,  the  laryngoscopic  mirror,  or  by  palpation  would 
be  insufficient. 

Diagnosis  is  usually  easy,  except  in  the  case  of  children  or 
lunatics.  Nervous  people  sometimes  complain  of  a  foreign 
body  being  present  in  the  throat,  when  nothing  is  there. 
This  is  a  case  where  the  patient  cannot  localize  the 
pain,  especially  when  deglutition  is  painless.  It  must  also  be 
recognized,  that  a  mere  scratching  of  the  mucous  membrane 
may  give  rise  to  the  belief  on  the  part  of  the  patient  of  the 
existence  of  a  foreign  body  in  the  throat. 


DISEASES  OF  THE  PHARYNX  139 

Complications  vary  according  to  the  nature  and  bulk  of 
the  foreign  body.  Some  scratches  on  the  mucous  membrane 
may  occasion  emphysema  or  acute  œdema  of  the  vestibule 
of  the  larynx,  even  ulcerous  perforations  of  the  large  vessels 
of  the  neck  and  retro-pharyngeal  abscesses,  with  caries  of  the 
cartilage. 

Treatment.  — ■  The  only  remedy  is  removal.  If  inflam- 
matory complications  occur  in  the  larynx,  tracheotomy  may 
be  necessary.  Once  the  nature,  form  and  locality  of  the 
foreign  body  are  recognized,  it  will  be  removed  through  the 
natural  tracts  or  by  external  pharyngotomy.  If  the  object 
is  smooth  it  may  be  pushed  down  into  the  oesophagus 
and  the  stomach.  Pains  may  remain,  especially  in  nervous 
people  ;  accordingly  a  tonic  and  antineurotic  treatment  is 
advisable. 

Paraesthesia  of  the  Pharynx. 

A  series  of  sensations  of  pain  and  uneasiness  generally 
occupying  the  pharyngeal  cavity,  which  the  appearance  of 
the  usually  normal  condition  of  the  mucosa  in  that  region 
cannot  explain. 

Symptomatology . — There  are  two  forms  of  paraesthesia  of 
the  pharyngeal  cavity — hypergesthesia  and  hyposesthesia. 

Hyper^esthesia  is  manifested  by  a  sensation  of  heat  and 
pain  in  the  pharyngeal  cavity.  The  patient  complains  of  the 
sensation  of  a  hot  iron  in  the  throat,  or  a  tingling  sensation, 
which  compels  him  to  attempt  to  clear  his  throat  continually. 

On  examination  the  tongue  is  found  to  rear  against  the 
depressor.  Reflexes  are  observed,  accompanied  with  exces- 
sive contraction  of  the  pharyngeal  cavity.  When  the  prac- 
titioner is  aware  of  these  nervous  disturbances,  he  readily 
observes  diffuse  redness  on  the  pharyngeal  wall  and  of  the 
suspected  region,  due  to  intense  contraction  of  the  muscles 
of  the  neck  by  the  patient,  to  the  consequent  venous  stasis 
and  to  the  breath  being  withheld.  Strangely  enough, 
energetic  brushing  and  painting  made  at  that  level  are 
easily  tolerated. 

Hypo.esthesia,   on    the  contrary,   is    manifested    by  the 


I40  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

sensation  of  a  foreign  bod}^  obstructing  the  throat — a  ball, 
thick  saliva,  or  fruit  peel — of  which  the  patient  tries  to  get 
rid.  He  hems,  clears  his  throat,  and  sometimes  succeeds  by 
violent  effort  in  detaching  a  viscous,  and  occasionall}'  blood- 
streaked  mucous  plug. 

A  singular  fact  about  this  is,  that  when  the  patient  is 
eating,  drinking,  or  even  sucking  a  lozenge,  he  feels  relieved  for 
some  moments,  and  often,  even  for  several  hours.  The  author 
thinks,  that  this  peculiarity  is  of  importance  in  differentiating 
the  really  painful  and  dysphagic  forms  and  the  more  or  less 
grave  and  acute  anginas  from  mere  parsesthetic  disturbances. 

Here  direct  examination  also  shows  complete  integrity  of 
the  pharyngeal  mucosa  and  of  the  whole  pharyngeal  cavit}-, 
and  a  mere  diminution  of  sensibility  in  that  region. 

The  general  disturbances  vary  according  as  the  affection 
is  observed  in  neuro-arthritic  or  psychopathic  subjects. 

Psychism,  indeed,  gives  to  those  disturbances  a  series  of 
clinical  peculiarities,  which  deeply  impress  the  practitioner 
unacquainted  with  such  cases. 

In  teachers  and  singers  a  true  phonophobia  is  observed. 

In  others  it  is  a  constant  anxiety,  increased  by  their 
repeated  examination  of  the  throat,  and  discovery  of  more 
or  less  hypertrophied  closed  follicles,  or  caseous  matter  in  the 
tonsils. 

Patients  suffering  from  hypoaesthesia  are  easily  examined, 
as  they,  being  accustomed  to  depress  their  tongue  and 
inspect  their  pharynx,  readily  let  the  latter  be  seen. 

Hypoaesthesia  usually  originates  in  an  emotion — sorrow, 
overwork,  or  in  the  very  fact,  that  the  patient  has  known 
somebody  who  had  succumbed  to  a  disease  of  the  throat.  The 
nervous  temperament  always  predisposes  to  that  affection. 

Prognosis  is  usually  benign.  It  may  be  grave  through  the 
state  of  anxiety  occasioned  by  those  nervous  disturbances. 

Treatment  should  be  both  general  and  local.  In  hyper- 
assthetic  forms  antispasmodics  should  be  prescribed — 
bromide,  cocainized  preparations,  painting  with  bromide 
and  glycerine,  emollient  gargles,  physical  exercise,  tonics 
and  general  diet. 


DISEASES  OF  THE  PHARYNX 


141 


In  hypoaesthetic  forms,  on  the  contrary,  antispasmodic 
treatment,  such  as  bromide,  should  be  carefully  avoided. 
It  should  preferably  be  attempted  to  rouse  the  sensibility 
by  means  of  mentholated  pigments  (i  :  50  or  i  :  30),  phar3-n- 
geal  douches,  energetic  spraying  of  the  pharyngeal  cavit}-, 
and,  if  need  be,  by  local  electrization. 

The  general  treatment  should  consist  in  the  use  of  valerian 
preparations,  and  especially  of  arsenic  and  strychnine  in  the 
form  of  tincture  of  nux  vomica  and  bitter  infusions  ;  in  hydro- 
therapy, physical  exercise,  and  in  a  thermal  cure  adapted  to 
the  constitution  of  the  subject. 

In  some  cases  a  suggestive  galvanic  cauterization  of  the 
pharyngeal  wall  will  suffice  to  cure  the  patient. 


Tuberculous  Pharyngitis. 

Tuberculosis  of  the  pharynx  may  commence  in  the  pharyn- 
geal wall.  It  is  then  of  the  same  type  as  has  been  already  de- 
scribed in  bacillary  angina 
— an  acute  miliary  form 
— isolated  lupus  of  the 
pharynx  being  almost  un- 
known. The  leading  sj-mp- 
toms  are  considerable  dys- 
phagia, deep  discoloration 
of  the  pharynx,  and  signs 
of  general  infection.  The 
treatment  is  that  of  ordin- 
arv  tuberculous  angina. 


Syphilis    of    the 
Pharynx. 

Secondary  syphilis  is 
rare  on  the  pharyngeal 
wall.  When  it  does  exist, 
it  coincides  with  er3'the- 
matous  angina  and  mucous  patches  on  the  pillars  and 
tonsils,  sometimes  even  on  the  uvula,  tongue,  and  lips. 


Fig.  64. 


142  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

Syphilitic  patches  on  the  pharynx  are  always  erosive,  the 
wall  being  reddish  and  tumefied.  Here  the  lesion  itself  has 
no  red  margin,  such  as  distinguishes  other  lesions  of  the  rest 
of  the  pharyngeal  cavity,  and  resembles  a  scratch  made  by  a 
nail  or  foreign  body.  It  is  covered  by  the  greyish  membrane, 
as  is  common  in  wounds  of  this  region. 

The  functional  symptoms  resemble  those  of  the  con- 
comitant angina. 

Tertiar}^  lesions  of  the  pharynx  consist  in  a  gummatous 
infiltration,  situate  in  the  lateral  part,  or  even  in  the  mesial 
portion,  of  the  wall.  There  are  found  enormous  sharply 
defined,  crateriform  ulcerations,  extending  to  the  naso- 
pharynx. 

Tumours  of  the  Pharynx. 

Benign  Tumours. 

Generally  speaking,  benign  tumours  of  the  pharynx  are 
comparatively  rare.  There  have  been  observed  myxomata, 
papillomata,  dermoid  cysts,  lipomata,  fibromata,  enchondro- 
mata,  osteomata,  angiomata,  and  even  aneurisms.  The 
tumours  origmate  either  in  the  posterior  wall  of  the  buccal 
pharynx,  on  the  lateral  surfaces,  or  at  the  level  of  the  inferior 
phar3-nx. 

Symptoms  are  very  variable.  At  the  outset  they  are  merely 
the  sensation  of  a  foreign  body,  troubles  of  deglutition,  and 
tickling  of  the  throat,  sometimes  causing  nausea. 

As  the  growth  advances,  the  symptoms  are  more  pro- 
nounced, and  respiration  and  deglutition  are  interfered  with, 
especially  if  the  tumour  is  pedunculated,  as  the  growth  may 
glide  down  into  the  larynx  or  œsophagus. 

The  result  of  direct  examination  depends  on  the  nature  of 
the  growth. 

1.  Lipoma. — The  lipoma  appears  as  a  reddish  growth,  on 
which  the  mucous  membrane  has  retained  its  normal  colour. 
It  is  sessile,  unilobular,  and  of  somewhat  hard  consistence. 

2.  Fibroma  very  much  resembles  the  preceding,  except 
that  it  maybe  sometimes  pedunculated.  The  diagnosis  often 
can  only  be  confirmed  by  histological  examination. 


DISEASES  OF  THE  PHARYNX  143 

3.  Enchondroma  and  Osteoma,  of  irregular  surface, 
though  smooth,  are  recognizable  by  their  consistency  and 
their  form.  Indeed,  they  resemble  a  simple  raising  of  the 
mucous  membrane,  and  adhere  closely  to  the  underlying 
tissues  with  which  they  appear  to  blend. 

4.  Papillomata,  generally  pedunculated,  and  accordingly 
mobile,  are  of  a  muriform  rosy  appearance. 

5.  Angiomata  have  a  deep  red  hue.  They  are  doughy, 
bosselated,  resilient,  and  reducible,  without  pulsation,  thus 
differing  from  aneurisms,  which  are  sometimes  found  on  the 
lateral  wall  of  the  pharynx,  along  the  course  of  the  pharyn- 
geal artery. 

The  laryngoscope,  palpation,  and  even  the  probe,  will  be  of 
help  in  the  diagnosis. 

Complications. — Sometimes  certain  mobile  growths  project 
into  the  larynx,  and  cause  violent  coughing,  suffocation,  and 
even  asphyxia.  In  other  cases  the  neoplasm  interferes  with 
the  epiglottis,  and  allows  the  food  to  pass  into  the  larynx. 

Course. — The  course  is  always  slow  and  progressive,  and 
may  continue  unperceived  for  years.  Some  of  those  benign 
growths  become  malignant. 

Diagnosis. — The  first  consideration  is  to  definitely  establish 
the  existence  of  the  growths,  as  they  are  very  often  confused 
with  the  projection  of  the  vertebral  bodies.  To  avoid  this  error, 
stand  directly  in  front  of  the  patient,  and  request  him  to  hold 
his  head  upright.  A  gumma  at  the  period  of  infiltration,  and 
a  chronic  retro-pharyngeal  abscess  may  in  the  same  way  be 
mistaken  for  a  growth.  The  development  of  the  syphilitic 
lesion  in  the  first  and  the  presence  of  fluctuation  in  the  second 
will  readily  determine  the  diagnosis.  It  is  fairly  easy  to 
differentiate  these  growths  by  the  eye,  the  only  important 
diagnosis  being  the  recognition  of  the  vascular  and  aneurismal 
tumours. 

Treatment  consists  in  extirpation,  generally  through  the 
mouth. 

According  to  circumstances  the  growth  should  be  removed 
with  the  cold  or  galvano-snare,  the  ecraseur,  the  cutting 
forceps,  the  galvano-   or  thermo-cautery.     If  respiration  is 


144  DISEASES  OF  THE  PHARYXX  AXD  LARYXX 

interfered,  with,  preliminary  tracheotomy  can  be  resorted  to. 
External  pharyngotomy  is  advisable  only  in  exceptional 
cases.  If  angiomata  and  aneurisms  endanger  life,  ligature 
of  the  dilated  vessel,  between  the  heart  and  the  aneurism, 
should  be  performed. 

Malignant  Tumours. 

These  are  primary,  or  more  frequently  secondary  by  direct 
propagation.     The  latter  are  more  frequent. 

Pathological  Anatomy.  —  The  primary  tumours  of  the 
pharynx  are  the  epitheliomata  and  the  sarcomata.  The  epi- 
thelioma is  usually  lobulated  and  of  the  pavemented  variety. 
All  kinds  of  sarcomata  are  to  be  seen  in  the  pharynx,  but  the 
fasciculated  is  the  most  frequent.  The  malignant  tumours 
of  this  part  develop  preferably  in  the  vicinit}'  of  the 
larynx. 

Symptoms. — At  the  onset  functional  symptoms  are  almost 
nil.  As  the  tumours  increase,  disturbances  of  deglutition 
appear,  a  desire  to  hem,  and  sometimes  even  sickness  and 
vomiting,  and  haemorrhage,  or  at  least  expectorations  of 
saliva  streaked  with  blood.  Very  soon  spontaneous  pains 
arise,  extending  to  the  nape  of  the  neck,  the  ear,  and  the 
angle  of  the  jaw,  and  later  on  dysphagia,  respirator}-  dis- 
turbances, with  alteration  in  the  timbre  of  the  voice. 

When  ulceration  appears  the  symptoms  become  intensified  ; 
saliA"ation  is  profuse,  viscid,  and  often  ichorous  and  sanious. 
The  breath  becomes  repulsively  fetid,  and  the  teeth  and 
gums  covered  with  a  thick  greyish  pultaceous  coating;  the 
neck  is  stiff,  and  the  general  health  changes  for  the  worse  ; 
the  patient  becomes  thin,  and  has  the  characteristic  facial 
appearance  of  those  affected  with  m.alignant  tumours  of  the 
mouth  or  pharyngeal  cavity. 

Examination  shows  in  epithelioma  a  red  warty  surface, 
the  edges  of  which  blend  into  the  neighbouring  tissues.  The 
tumour  is  bosselated,  resilient,  and  painful.  It  bleeds  readily, 
When  ulceration  sets  in,  the  centre  of  the  tumour  becomes 
hollowed,  and  purulent,  and  is  covered  with  a  greyish  coating, 
while  the  edges  of  the  base  begin  to  bud,  forming  an  irregular 


DISEASES  OF  THE  PHARYNX  I45 

red,  sanious,  mushroom-like  growth.   The  edges  are  fixed,  and 
are  surrounded  by  swollen  infiltrated  mucous  membrane. 

The  sarcoma  appears  as  an  irregular  reddish  budding 
growth,  sometimes  pedunculated.  It  is  softish  in  consistency  ; 
the  neighbouring  structures  being  slightly  or  not  at  all 
infiltrated. 

Complications  of  cancer  of  the  pharynx  are— oedema  of 
the  neighbouring  parts;  onsets  of  suffocation  and  asphyxia: 
haemorrhages  and  disturbances  of  deglutition,  so  grave  as  to 
prevent  the  alimentation  of  the  patient. 

The  course  of  those  tumours  is  generally  rapid.  After 
being  stationary  for  several  months  they  develop  quickly, 
invade  the  neighbouring  parts,  making  the  pharynx  immobile, 
obstructing  the  œsophagus,  and  rapidly  affecting  the  general 
health  of  the  patient  by  producing  a  characteristic  cachexia, 
that  is  due  not  only  to  the  nature  of  the  neoplasm,  but  to  the  in- 
tolerable pain  felt  by  the  patient,  to  the  trouble  of  deglutition, 
and  to  the  penetration  of  septic  particles  into  the  organism. 

Diagnosis  is  based  at  the  outset  on  the  age  of  the  patient, 
the  presence  of  spontaneous  pain,  sanguinolent  expectora- 
tion, adenopathy,  and  the  course  of  the  disease. 

These  tumours  may  be  mistaken  for  a  syphilitic  gumma, 
but  their  deep  ulceration  with  sharply-defined,  irregular,  and 
torn  edges,  should  facilitate  the  diagnosis.  If  doubt  still 
remains,  it  may  be  dispelled  by  specific  treatment. 

Only  hybrid  cases  are  difficult,  because  the  mixed  treat- 
ment acting  on  the  syphilitic  element  may  lead  to  the 
beUef,  that  the  disease  is  of  venereal  origin.  Functional  dis- 
turbances are  of  great  diagnostic  importance.  The  existence 
of  spontaneous  pain  and  of  sanious  expectoration  point  to  a 
neoplasm.  The  presence  of  hard  monoglandular  masses, 
adherent  and  bosselated,  and  generally  painful,  indicate 
epithelial  degeneration. 

To  determine  the  true  nature  of  the  neoplasm,  it  will  be 

sufficient  to  take  a  portion  of  it  for  histological  examination. 

Epitheliomatous  growths  cannot  be  treated  efficaciously. 

A  radical  operation  is  almost  impossible.     The  results  of  the 

operation  are  grave,  and,  as  a  rule,  the  tumour  grows  again. 

10 


146 


DISEASES  OF  THE  PHARYNX  AND  LARYNX 


In  the  case  of  a  pedunculated  sarcoma  the  tumour  should 
be  removed  by  the  natural  tract,  if  necessary  with  the  assis- 
tance of  tracheotomy.  The  base  of  the  growth  should  be 
cauterized  by  the  galvano-  or  thermo-cauter3^ 

Lateral  pharyngotomy,  with  or  without  temporary  resec- 
tion of  the  inferior  maxilla,  ma}-  be  resorted  to  :  but,  to  be 
useful,  such  an  intervention  must  be  early, because  the  chances 
of  success  diminish  when  the  growth  is  ulcerated. 

If  external  operation  is  employed,  the  best  method  is  the 
Kronlein  process,  which  may  be  combined  with  Orlow's. 


Fig.  65. — Kronlein's  Line  of  Inxision  is  indicated  in  Red. 


Kronlein's  consists  in  making  a  curved  incision  originating 
in  the  labial  commissure,  extending  downwards  to  the  level 
of  the  hyoid  and  ascending  upwards  to  the  mastoid  apophysis. 
In  the  Orlow-Kronlein  process  the  incision  begins  at  the 
middle  of  the  lower  lip  towards  the  chin,  and  follows  the 
direction  already  given. 

In  the  Kronlein  incision  the  soft  parts,  thus  cut  layer  by 
layer,  lay  bare  the  whole  submaxillary  region  and  the  large 
vascular  vessels. 

During  this  first  operation  the  region  is  freed  of  all  infil- 
trated glands,  and  the  submaxillary  gland  is  removed.  Then, 
after  the  external  carotid,  and  sometimes  even  the  common 


DISEASES  OF  THE  PHARYNX 


147 


carotid,  have  been  ligatured,  the  maxilla  is  laid  bare  in  front 
of  the  masseter,  and  sawn  obliquely.  The  two  portions  are 
levered  up,  so  as  to  lift  the  upper  portion  upwards  and  out- 
wards, and  the  horizontal  portion  forward. 

This  operation  is  performed  under  chloroform  in  the  usual 
lateral  decubitus,  the  tongue  being  pulled  forward  by  a  thread. 
The  buccal  cavity  or  the  pharyngeal  wall  is  then  opened  to 
permit  of  the  tumour  being  rem^oved. 

Generally  haemorrhage  stops  as  soon  as  the  neoplasm  is 
taken  3iWSLy.     This  removal  should  be  quickly  performed,  and 


Fig.  66. — Orlow's  Line  of  Incision  is  marked  in  Red. 


great  care  exercised  to  prevent  the  blood  entering  the  trachea, 
which  constitutes  the  gravest  danger  of  the  operation. 

It  is,  as  a  rule,  unnecessary  to  practise  preliminary  tracheo- 
tomy, if  the  light  of  the  frontal  mirror  is  adequate. 

The  removal  of  the  neoplasm  having  been  effected,  the 
deep  region  should  be  sutured  with  catgut  and  the  wound 
plugged  with  iodoform  gauze  soaked  with  hydroxyl  in  sterilized 
water.  The  two  portions  of  the  maxilla  should  be  joined  with 
silver  wire  and  the  wound  partly  closed,  leaving  room  for  the 
drainage-tubes. 

Alimentation  of  the  patient  should  be  effected  by  liquid 
enemata  for  three   or  four  days,   then   through  the   buccal 

10 — 2 


148  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

cavity  with  the  assistance  of  the  œsophageal  tube,  if  the 
condition  of  the  patient  allows  it.  It  is  rare  that  the  patient 
will  permit  the  tube  to  remain  long,  on  account  of  its  irritating 
effect. 

The  complications  are  those  customary  to  operations  in 
this  region,  especially  infectious  broncho-pneumonia;  haemor- 
rhages may  also  supervene  at  the  eighth  or  even  the  twelfth 
day  after  operation.  Very  often  some  ramification  of  the 
facial  nerve  is  cut,  and  the  patient's  face  is  thereby  altered. 

The  mouth  must  be  kept  absolutely  clean  with  antiseptic 
solutions,  especially  with  diluted  hydroxyl,  to  favour  healing 
and  diminish  infection  of  the  wound  ;  but  it  is  almost 
impossible  to  prevent  this. 

Constrictions  of  the  Inferior  Pharynx. 

True  annular  constrictions  are  usually  caused  by  tertiary 
syphilis,  lupus,  and  burns. 

Symptoms.  —  The  stenosis  of  the  base  of  the  pharynx 
develops  generally  very  slowly,  and  accordingly  the  onset 
is  insidious. 

For  months  or  even  years  atresia  may  be  in  progress,  and 
cause  no  trouble  but  slight  uneasiness  in  deglutition.  If  con- 
striction becomes  aggravated,  there  appears  a  series  of  local 
symptoms,  among  which  occur  penetration  of  liquid  food 
into  the  trachea,  and  change  of  voice.  At  a  more  advanced 
stage  respiration  is  interfered  with,  stertorous  breathing 
appears,  deglutition  of  solid  food  becomes  impossible,  and 
only  liquids  pass  through  the  very  narrow  orifice. 

At  this  stage  the  patient  is  in  a  state  of  profound  collapse. 
Cachexia  supervenes,  and  the  voice  is  weak  and  stifled. 

Laryngoscopic  examination  shows  the  base  of  the  tongue 
more  or  less  glued  to  the  pharyngeal  wall,  enveloping  the 
whole  epiglottis,  which  may  be  healthy  or  partly  destroyed. 
The  opening  into  the  pharyngeal  cavity  is  very  reduced, 
being  2  to  3  millimetres  broad  and  3  to  4  millimetres  in 
length. 

Sometimes  the  yellowish,  very  tense,  fibrous  bridles  are 


DISEASES  OF  THE  PHARYNX 


149 


projected  from  before  backwards,  forming  an  infundibulum, 
at  the  bottom  of  which  is  the  small  aperture. 

Treatment. — Local  medication  is  usually  applied  too  late 
to  be  useful,  and  especially  so,  if  the  patient  has  attained 
to  the  stage  of  stertorous  breathing. 

If  the  constriction  is  too  pronounced,  tracheotomy  must 


Fig.  67. — Appearance  of  the  Inferior  Pharynx  in  a  Case  of 
Concentric  Stenosis. 

The  base  of  the  tongue,  the  posterior  and  lateral  walls  of  the  pharynx,  are 
united  by  a  series  of  fibrous  strictures,  forming  a  true  membranous 
diaphragm. 

be  resorted  to,  and  it  is  preferable  to  perform  it  on  the  very 
middle  of  the  trachea,  below  the  cricoid.  Should  the  orifice 
be  wide  enough  to  allow  of  breathing,  simple  dilatation,  with 
different  kinds  of  oesophageal  tubes  (Schrotter's  or  Beniquet's), 
may  be  tried.  If  mere  tubage  is  not  sufficient,  some  incisions 
can  be  made  with  the  galvano-cautery.    Dilatation  by  sudden 


I50 


DISEASES  OF  THE  PHARYXX  AXD  LARYNX 


divulsion    may  also  be    employed,   but   with    less    beneficial 
result. 

Electrolysis  seems  to  be  a  good  remedy,  but  is  difficult 
and  protracted. 


Fig.  68. — Schrotter's  Tubes  for  Dilating  the  Inferior  Larynx. 


If  incision  is  practised  on  the  fibrous  folds,  there  is  a  danger 
of   cutting  branches   of  the   pharyngeal  artery  and  causing 


haemorrhage. 


Jacobson  advises  in  such  cases  lateral  pharyngotomy,  so 
as  to  prevent  haemorrhage  and  counteract  the  constriction. 


PART    II 

LARYNX 


CHAPTER  I 

EXAMINATION  OF  THE  LARYNX  AND  OF  THE  TRACHEA 

MouRA-BoUROUiLLOu's  method  ^of  illumining  the  throat, 
consisting  of  converging  luminous  rays  from  a  lamp  furnished 
with  a  convex  lens,  is  nowadays  superseded  by  that  of  Turck 
and  Czermack,  which  is  simpler  and  easier,  the  rays  from 
a    luminous  source,   as  intense  as  possible,  being  reflected 


Fig.  69. — Frontal  ]^Iirror,  with  Spectacle  Attachment. 

into   the    mouth    of  the    patient    by  the  aid  of  a  concave 
mirror. 

The  reflection  mirror  now  generally  adopted  has  a  frontal 
band,  a  spectacle  mount  or  a  spring  fixing  it  on  to  the 
nape  of  the  neck. 

151 


152  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

Specialists,  who  have  electric  light,  use  Clar's  mirror  or 
Hellot's  photophore. 


Fig.  70. — Clar's  Mirror,  with  Forehead  Band. 


Fig.  71. — Helot's  Electric  Photophore,  with  Steel  Folding 
Head  Band. 


Laryngoscopic  Examination. 

In  order  to  practise  this,  first  place  the  patient  vis-à-vis, 
with  his  head  slightly  inclined  backwards.  Secondly,  grasp 
the  tongue  with  a  linen  cloth  between  the  thumb  and  the 


EXAMINATION  OF  THE  LARYNX  AND  TRACHEA 


153 


index  finger,  and  draw  it  gently  outwards.  Thirdly,  direct 
the  rays  of  light  in  front  of  the  uvula.  Fourthly,  warm  the 
mirror  to  prevent  its  being  tarnished  by  the  patient's  breath. 


Fig.  72. — MoRELL  Mackenzie's  Laryngoscopic  Lamp,  with  Racket 
TO  Raise  and  Lower. 

and  after  testing  its  temperature  on  the  back  of  the  hand, 
introduce  it  into  the  buccal  cavity.  The  handle  of  the 
mirror  should  beheld  in  such  a  way,  that  the  mirror  may  pass 


Fig.  73. — Method  of  Holding  the  Mirror  to  Introduce  it  into 
the  Mouth. 


through  the  dental  arch  parallel  to  the  surface  of  the  tongue 
and  the  palatine  vault,  touching  neither  the  tongue  nor  the 
teeth  nor  the  vault.     The  uvula  is  gently  pushed  upwards 


154  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

and  backwards,  so  that  the  reflecting  surface  is  directed 
downwards  and  shghtly  forwards  towards  the  laryngeal 
cavity. 

The  mirror  being  in  position,  the  patient  is  asked  to  pro- 
nounce in  a  high  tone  the  sound  '  eh.'  This  effort  causes 
the  epiglottis  to  rise,  and  inspection  of  the  larynx  is  usually 
easy  ;  another  vowel  has  not  the  same  effect. 

It  must  be  remembered,  that,  up  to  a  certain  limit,  the 
more  acute  the  sound  is,  the  better  the  epiglottis  rises  and 
uncovers  the  interior  of  the  cavity  to  be  examined.  In  order 
to  see  that  the  mobility  of  the  muscles  is  not  interfered 
with,  slow  respiration  should  be  practised. 

With  children  and  nervous  patients  assistance  may  be 
required  to  keep  the  head  backwards.  If  the  pharyngeal 
cavity  is  really  too  sensitive,  the  patient  may  be  gradually 
prepared  for  the  examination  by  frequent  painting  of  the 
soft  palate  and  pharynx  with  a  bromide  solution,  such  as — 

H     Hydrochloride  of  cocaine  ...         lo  centigrammes      gr.  3 
Bromide  of  potassium         ...  i  gramme  gr.  30 

Glycerine  ...  ...         30  grammes  3xiii 

A  more  important  obstacle  to  examination  is  the  inability 
of  the  epiglottis  to  rise,  as  is  usually  the  case  in  children 
under  five  or  six  years  of  age  ;  and  for  that  reason  elevators 
of  the  epiglottis  (Stoerck,  etc.)  have  been  invented.  Some 
authors  recommend  that  a  thread  should  be  passed  through 
the  epiglottis  by  means  of  a  curved  needle.  It  is,  however, 
generally  possible  to  overcome  this  impediment  by  direct 
laryngoscopy. 

Direct  Laryngoscopy. 

Some  years  ago  Kirstein  proved,  that  the  larynx  could 
be  viewed  directly  without  the  aid  of  the  mirror  by  the 
patient  having  his  head  inclined  strongly  backwards,  and 
the  electric  light  directed  to  the  base  of  the  tongue,  that 
organ  being  strongly  drawn  downwards  and  forwards  by 
means  of  a  special  tongue-depressor  introduced  down  to  the 
insertion  of  the  epiglottis.     In  that  way  the  epiglottis  rises 


EXAMINATION  OF  THE  LARYNX  AND  TRACHEA      155 

and  the  larynx  mounts  upwards,  thus  permitting  the  whole 
cavity  to  be  examined.     Escat   happily  modifies   Kirstein's 


Fig.  74. — Kirstein's  Tongue- 
depressor. 


Fig.  75. — Escat's  Tongue-de- 
pressor, FOR  Direct  Laryngo- 
scopy. 


depressor  by  making  it  double-pronged,  so  as  to  adjust  itself 
to  each  side  of  the  median  glosso-epiglottic  fold. 


Auto-laryngoscopy. 

This  was  iirst  practised  by  Czermack.  There  are  two 
methods  of  self-examination  of  the  throat — by  placing 
a  mirror  above  the  source  of  light  to  catch  the  reflection 
from  the  throat-mirror,  or  by  means  of  a  mirror  with  a 
concave  surface,  the  inferior  part  of  which  permits  rays 
coming  from  without  to  pass.  The  operator,  standing  in 
front  of  a  window,  lights  up  his  pharynx,  and  at  the  same 
time  sees  the  image  of  his  larynx. 


156 


DISEASES  OF  THE  PHARYNX  AND  LARYNX 


Laryngoscopic  Image. 

It  may  not  be  useless  to  recall,  that  the  image  reflected 
by  the  mirror  is  not  upside  down,  but  only  raised  in  position. 
The  anterior  commissure  appears  high  up  in  the  mirror,  while 


Fig.  76. 


-Diagram  showing  the  Position  of  the  Différent  Parts 
OF  THE  Larynx  and  their  Reflection. 


Plane  of  the  mirror  ;  /,  larynx  ;  0,  eye  of  the  observer;  a,  the  arytenoids; 
oe,  the  aryepiglottic  folds  ;  and  e,  the  epiglottis,  which  is  reflected  at«,  aé, 
and  é. 


the  posterior  portion  is  low  down  on  the  reflecting  surface. 
The  lateral  walls  do  not  change  their  position  in  any  way, 
but  the  right  vocal  cord  of  the  subject  appears  to  the  left 
of  the  observer.      The  laryngeal  image   from  above  down- 


FiG.  77. — Appearance  of  the  Larynx  during  Phonation. 

pv,  Vocal  apophysis  ;  a,  arytenoid  ;  C07h,  posterior  commissure  (arytenoidean)  ; 
es,  cartilage  of  Santorini  ;  cw,  cartilage  of  Wrisberg  ;  ch,  cornu  of  the 
hyoid  bone;  sp,  hyoid  fossa;  fi,  ventricular  band. 

wards,  or  in  reality  from  before  backwards,  comprises  the 
base  of  the  tongue,  which  is  rosy  and  irregular,  somewhat 
swollen  in  parts,  and  a  little  farther  down  the  epiglottis,  of  a 
yellowish  or  rosy  yellow  aspect,  and  of  variable  form.    On  each 


EXAMINATION  OF  THE  LARYNX  AND  TRACHEA      157 

side  of  this  operculum  the  aryepiglottic  folds  appear  slightly 
pyriform,  and  of  a  rosy  appearance,  going  in  a  downward  direc- 


FiG.  78.— Showing  THE  Angle  of  Incidence  and  of  Reflection  during 

THE    LaRYNGOSCOPIC    AND    SUBGLOTTIC    EXAMINATION. 

A,  Mirror  ;  B,  position  of  the  subglottic  mirror  ;  C,  left  vocal  cord 


tion  in  the  mirror,  although  they  really  go  backwards  towards 
the  arytenoids.  In  their  substance  and  posteriorly  are  two 
small  yellowish  projections — the  cartilages  of  Wrisberg  and 


158  DISEASES  OF  THE  PHARYNX  AND  LARYNX 


Fig.  79. — Types  of  the  Normal  Epiglottis. 


Fig.  80.— Representing  the  Image  of  the  Larynx  B  in  the 
Mirror  A. 

ac,  Anterior  commissure  ;  pc,  posterior  commissure  ;  r,  right  cord  ; 
/,  left  cord,  showing  a  polyp. 


EXAMINATION  OF  THE  LARYNX  AND  TRACHEA      159 


Santorini — crowning  the  arytenoids.  During  the  emission 
of  the  sound  'eh'  those  two  cartilages  are  in  juxtaposi- 
tion mesially,  closing  the  intercartilaginous  glottis.  During 
inspiration,  on  the  contrary,  they  separate  and  allow  the 
interarytenoid  region  to  be  seen  —of  a  paler,  often  irregular 
appearance. 

Within  the  aryepiglottic  folds 
are  seen  two  surfaces  of  a 
brighter  rose  colour  in  a  direc- 
tion from  before  backwards, 
therefore  from  above  down- 
wards in  the  mirror,  extending 
from  the  arytenoid  to  the  base 
of  the  epiglottis.  Those  are  the 
false  cords,  or,  to  be  more 
precise,  the  ventricular  bands. 
Below  those  bands  are  the 
ventricles  of  Morgagni,  which 
stand  out  clearly  as  a  dark  red 
or  brown  line.  Below  and 
within  the  ventricles  appear  two 
flattish  ribbons,  varying  in  size 
according  to  the  individual,  and 
having  normally,  especiall}^  in 
women  and  children,  a  shining 
appearance  like  the  iine  enamel 
of  the  teeth.  Those  are  the  ^ 
true  vocal  cords. 

During  inspiration  the  hypo- 
glottic  region,  the  rings  of  the 
trachea,  and  even    the   orifices 
of  the  bronchi,  may  be  perceived 
as  concentric  half-circles  of  a  yellowish  appearance  on  the 
mucous  membrane,  which  is  rosy. 

The  vocal  cords  seen  from  below  (hypoglottic  laryngo- 
scopy) are  rosy,  like  the  rest  of  the  vocal  mucous  mem- 
brane. 


Fig.  81.  —  Casper's  Handle, 
furnished  with  ax  elec- 
TRIC Lamp,  whose  Light  is 

REFLECTED  DIRECTLY  DOWN- 
WARDS BY  A  Prism  placed 
AT  THE  Extremity  of  the 
Instrument. 

I,  Reflecting  prism  ;  2,  electric 
contact  button  ;  3,  points  of 
contact  ;  4,  screw  for  adjust- 
ing this  handle  to  Kirstein's 
(Fig.  74)  or  Killian's  tubes. 


Those  rings  stand  out 


i6o 


DISEASES  OF  THE  PHARYNX  AND  LARYNX 


Tracheoscopy  and  Bronchoscopy. 

Tracheoscopy  is  generally  practised  in  the  same  way  as 
laryngoscopy. 

By  taking  advantage  of  a  deep  inspiration  to  illumine  the 
interior  of  the  tracheal  tract,  it  is  sometimes  possible  to  see 


-.,^^ 


x 


Fig.  82. — Appearance  of  the  Larynx  during  Deep  Inspiration. 

ge,  Glosso-epiglottic  folds,  medial  and  lateral  ;  u,  superior  surface  of  the 
epiglottis;  /,  epiglottis,  free  border  ;  f,  cushion  ;  y,  ventricle  of  Morgagni  ; 
vh,  ventricular  band  ;  vc,  vocal  cord  ;  pv,  vocal  apophysis  ;  ae,  aryepiglo'.tic 
folds;  cW ,  cartilage  of  Wrisberg  ;  cS,  cartilage  of  Santorini  ;  com,  inter- 
arytenoidean  commissure  ;  cr,  cricoid  cartilage  ;  t,  rings  of  the  trachea. 

by  tracheoscopy  down  to  the  bifurcation,  and  even  a  portion 
of  the  opening  of  the  right  bronchus  if  the  head  of  the  patient 
is   placed    slightly  to   the    left    and    upwards   (Kirstein  and 


a^ 


rrc 


t- — Ivt 


Fig.  83. —Appearance  of  the  Anterior  Wall  of  the  Trachea,  and 
OF  the  Orifice  of  the  Great  Bronchi. 

at.  Anterior  wall  of  the  trachea  ;  rvc,  right  cord  ;  Ivc,  left  cord  ;  vh,  right 
bronchus  ;  Ih,  left  bronchus  ;  hz,  bronchial  spur. 

KiUian).     This  is  an  indirect    method,  as  the  image  alone 
of  the  organ  to  be  examined  is  seen. 

After   tracheotomy   the   trachea   and    the   first   bronchial 


EXAMINATION  OF  THE  LARYNX  AND  TRACHEA      i6i 

division  may  be  inspected  with  the  aid  of  a  small  mirror 
placed  in  the  tracheal  opening,  the  air  passages  being 
previously  anaesthetized  with  cocaine  (i  :  lo).  By  turning 
the  mirror  upwards  the  subglottic  region  may  be  seen. 

Killian's  method  is  practised  in  two  distinct  ways — either 
through  a  tracheal  orifice  (inferior  bronchoscopy),  or  by  the 


Fig.  84. — Superior  Tracheoscopy  and  Bronchoscopy.     (After  Killian.) 
This  figure  shows  the  first  stage  in  the  introduction  of  the  tube. 


mouth  (superior  bronchoscopy).  In  both  cases  the  tracheo- 
bronchial mucous  membrane,  or  the  laryngo  -  tracheo  - 
bronchial,  must  be  anaesthetized  with  cocaine  solution  (10  to 
20  per  cent.). 

Inferior    Bronchoscopy    is    by  far    the    simplest    and 
easiest  method,  and    may  be  practised  without  narcotics — 

II 


i62  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

at    least,   in    adults— the    operator    being    in    front    of    the 
patient. 

Once  the  tracheotomy  tube  is  removed,  the  head  of  the 
patient  should  be  thrown  well  backwards  to  straighten  the 
tracheal  passage.  Then,  with  Killian's  tracheo-bronchial 
tube,  aided  by  Clar's  frontal  mirror,  or,  still  better,  by  fixing 


Fig.  85.  — Second  Stage  of  Tracheoscopy  and  Bronchoscopy. 
(After  Killian.) 

The  tube  has  penetrated  to  the  bronchi. 

it  to  Caspar's  handle,  introduce  the  tube,  which  should  be 
warmed  and  coated  with  vaseline,  into  the  trachea  down 
to  the  bronchial  bifurcation.  When  at  this  level,  if  it  is 
desired  to  introduce  the  tube  into  the  right  or  left  bronchus, 
move  the  head  of  the  patient  in  the  contrary  direction.  The 
tube  is  then  pushed  gently  down  to  the  first  ramification, 


EXAMINATION  OF  THE  LARYNX  AND  TRACHEA 


163 


Fig.  87.— Killian's  Cotton-wool  Carrier 
FOR  THE  Trachea  and  the  Bronchi. 


II — 2 


104 


DISEASES  OF  THE  PHARYXX  AXD  LARYXX 


through  which  it  may  easily  pass,  if  it  is  not  too  large.  If 
mucus  is  present,  it  may  be  removed,  either  by  a  cotton 
mop.  or  with  the  special  pump  used  by  Kilhan. 

In  Superior  Bronchoscopy  the  patient  may  either 
sit  in  front  of  the  observer  after  cocainization,  or  He  on 
his  back  under  chloroform.     Killian  thinks,  that  the  narcotic 


Fig. 


-KiLLiAx's  Phantom  for  Practising  Bronchoscopy  and 

ŒSOPHAGOSCOPV. 


has  the  advantage  of  making  the  muscles  of  the  neck  more 
relaxed,  and  facilitating  the  introduction  of  the  tube.  Once 
the  patient  is  asleep,  draw  his  head  a  httle  beyond  the 
table  and  depress  it.  Then  press  the  tongue  down,  and 
insinuate  the  tube  first  beyond  the  epiglottis,  then  between 
the  vocal  cords  at  the  level  of  the  interarytenoid,  and  then 


EXAMINATION  OF  THE  LARYNX  AND  TRACHEA       165 

penetrate  into  the  trachea,  taking  advantage  of  the  movement 
of  inspiration.     Cocaine  will  favour  the  intubation. 

If  the  patient  is  not  under  chloroform,  place  him  in  front 
of  the  operator,  with  the  head  strongly  pushed  backwards,  to 
straighten  the  laryngo-tracheal  passage. 


FiG.  89. — Garel's  Electric  Laryngo-phantom.     (Reproduced  from  a 
Negative  by  Bassols  Prim.) 

a,  b,  Metal  case,  inside  which  is  placed  an  artificial  larynx;  c,  cell  for  ringing 
the  electric  bell  ;  d,  terminal  for  fixing  the  electric  probe  ;  /,  terminal 
connecting  the  thread  correspondmg  to  the  point  to  be  touched  ;  g,  repre- 
sentation of  the  different  points  of  the  larynx  possible  to  touch  ;  m,  bell 
ringing  to  indicate  the  result  of  the  experiment  ;  p,  handle  of  the  electric 
probe  ;  /,  cover  of  the  metal  tube. 


The  length  and  diameter  of  the  bronchoscopic  tubes  vary 
according  to  different  individuals.  With  adults  Kiliian 
recommends  tubes  from  g  to  11  millimetres  in  diameter  and 
from  16  to  25  centimetres   in   length   for  inferior  broncho- 


i66 


DISEASES  OF  THE  PHARYNX  AND  LARYNX 


scopy,  and  from  20  to  35  centimetres  for  superior  broncho- 
scopy. The  tube  must  always  be  coated  with  vasehne, 
warmed  and  steriHzed.  It  must  be  inserted  gently  under  the 
eye  of  the  operator.  If  foreign  bodies  are  to  be  removed, 
special  instruments  are  required.  Killian  has  invented  a 
bronchoscopic  phantom  to  train  beginners.  The  cleansing 
of  the  visible   area  is  effected  with  plugs  of  wool,   suction 


Fig.   90.— Garel's  Electric  Laryngo-phantom. 

An  artificial  larynx  furnished  with  eight  electric  conductors,  each  correspond- 
ing to  small  electric  contacts  scattered  in  difl'erent  regions  of  the  larynx. 

pump,   or  with  a  bronchoscopic  tube  with  a  double  orifice 
also  invented  by  Killian. 


Laryngoscopic  Practice. 

The  operator,  having  both  hands  occupied,  must  ask  the 
patient  himself  to  hold  the  tongue  with  his  left  hand,  if  the 
doctor  is  right-handed,  and  vice  versa. 


EXAMINATION  OF  THE  LARYNX  AND  TRACHEA      167 


Some  authors  (Baratoux  and  Garel)  have  invented  electric 
laryngo-phantoms  for  training  beginners. 

Stroboscopy. 

Examination  with  the  stroboscope  is  used  specially  to 
observe  the  movements  of  the  cords.  Indeed,  a  vocal 
cord,  which  seems  motionless  on  ordinary  laryngoscopy, 
appears  animated  with  movements  perceptible  with  Spiess' 
apparatus.     This    instrument    should    therefore    be    used    in 


Fig.  91.— Garel's  Apparatus  for  Photographing  the  Larynx. 

A,  Laryngeal  mirror  ;  B,  lever  to  close  the  shutter  ;   C,  screw  for  moving  the 
film  after  each  pose. 

cases  of  paralysis,  to  distinguish  between  partial  and  total 
lesions.  The  stroboscope,  based  on  the  same  principles 
as  the  kinetoscope  and  cinematograph,  consists  of  a  double 
electric  photophore  placed  before  the  eye  of  the  observer. 
By  the  help  of  very  simple  mechanism,  put  in  motion  by 
an  electric  motor,  diaphragms  and  orifices  pass  at  regular 
intervals  before  the  eye  of  the  observer,  and  make  on  his  retina 


î68  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

a  series  of  successive  images,  allowing  him  to  see  the  move- 
ments of  the  cords.  The  instrument  emits  a  sound,  which  the 
patient  has  to  reproduce,  in  order  to  make  the  number  of  the 
vibrations    of  the    thyro-arytenoid    folds    coincide  with   the 


Fk;.  92.  — Spiess'  Stroboscope. 

I,  Electric  lamps  with  bull's-eyes;  2,  tube  to  be  placed  in  the  mouth  of  the 
operator,  who  sounds  the  note;  3,  electric  cord;  4,  tube  fitted  to  the 
mechanism  which  moves  the  diaphragms. 


number  of  the  interruptions  of  the  apparatus.  As  a  woman's 
voice  is  an  octave  higher,  inspection  is  made  through  a  smaller 
aperture  placed  a  little  below  the  former,  which  renders 
more  rapid,  and  consequently  more  numerous,  the  interrup- 
tions of  the  opaque  diaphragm. 


CHAPTER  II 

DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX 

Circulatory  Disorders. 

.Anaemia  is  observed  chiefly  in  subjects  debilitated  by  repeated 
haemorrhages  or  general  affections  (chlorosis,  leukaemia).  It 
accompanies  cancer,  tuberculosis,  Bright's  disease,  etc. 

In  bacillary  affections  anaemia  of  the  pharynx  and  the 
larynx  may  be  very  early  and  so  pronounced,  that  some 
authors  insist  on  the  immediate  and  careful  examination  of 
the  lungs  of  a  patient  affected  with  this  discoloration  of  the 
pharynx  and  larynx. 

On  laryngoscopic  examination  the  soft  palate,  the  folds, 
and  the  ventricular  bands  present  a  pale,  rather  yellowish 
coloration,  with  some  vascular  arborescence.  The  vocal  cords 
have  lost  their  smooth  and  shining  appearance. 

The  diagnosis  of  those  circulatory  troubles  is  very  simple  ; 
they  are  recognized  only  by  laryngoscopic  examination, 
functional  symptoms  being  absent. 

Hyperaemia — Congestion. 

Laryngeal  congestion  appears  under  two  forms,  active  and 
passive. 

Passive  congestion,  or  hyperaemia,  is  associated  with 
heart  disease,  chronic  affections  of  the  digestive  tract,  or 
compression  of  the  veins  {e.g.,  in  the  effort  of  vomiting 
or  strenuous  cough). 

Active  congestion  is  frequently  the  syndrome  of  a 
general  affection.  It  occurs  often  during  the  course  or  at 
the  beginning   of  eruptive  fevers,  after  sudden   changes   of 

169 


ijo  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

temperature,  or  as  the  effect  of  cold  on  the  throat  or  feet. 
Inhalation  of  irritating  vapour,  tobacco  smoke,  and  alcoholism 
are  other  causes  of  this  aifection. 

Vocalists  especially,  when  they  sing  in  a  heated  room  or  in 
the  open,  particularly  at  the  seaside,  or  when  they  sing 
falsetto,  or  have  to  change  their  voice,  are  exposed  to  the 
disease  in  question.  It  occurs  also  among  certain  women 
before  or  during  the  period  of  menstruation.  Sometimes  it 
is  the  result  of  sexual  excitement.  There  is  a  marked 
relationship  between  the  uterus  and  the  larynx. 

Laryngeal  congestion  occurs  also  as  a  consequence  of 
lesions  in  the  nasal  mucous  membrane,  either  by  direct 
propagation  or  as  a  reflex  phenomenon.  It  is  also  a  neces- 
sary symptom  of  voice-breaking. 

It  is  met  with  in  tuberculosis,  naso-phar3-ngeal  catarrhs, 
and  chronic  inflammations  of  the  accessory  cavities  of  the 
nose.  It  may  occur  after  the  ingestion  of  certain  drugs,  as 
iodide  and  bromide  of  potassium,  ipecacuanha,  etc. 

Symptoms. —  In  slight  forms  S3'mptoms  may  be  absent. 
Usually  functional  disturbance  consists  in  a  feeling  of  pain, 
burning  and  tickling  in  the  pharyngeal  cavity.  The  cough 
is  paroxysmal  and  dry. 

The  timbre  of  the  voice  is  lowered,  becoming  husky  and 
less  sonorous,  and  vocalists,  especially  women,  sing  with  diffi- 
cult}' and  without  expression.  If  the  congestion  is  intense, 
the  voice  may  break  and  stop  during  the  production  of 
certain  notes. 

The  objective  symptoms  are  similar  in  the  active  and 
passive  forms.  According  to  the  intensity  of  the  lesion,  the 
coloration  of  the  vocal  mucous  membrane  varies  from  light 
red  to  a  deeper  hue.  The  ventricular  bands  and  the  posterior 
region  of  the  larynx  are  the  most  severely  attacked,  but  the 
cords  may  be  affected  throughout  their  length.  Sometimes 
the  cords  are  coloured  throughout  their  whole  extent.  They 
are  usually  rosy  or  red  only  on  their  edges,  and  more 
colourless  on  their  surface,  without  any  trace  of  infiltration. 
The  presence  of  paretic  changes  suggests  inflammation  rather 
than  a  simple  laryngeal  redness. 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     171 

Course,  Duration,  and  Termination. — The  course  of  the 
affection  is  very  variable.  It  depends  on  the  cause  and 
intensity  of  the  congestion.  Sometimes  the  disease  is 
transitory,  but  often  it  may  last  for  several  days.  The 
tendency  to  congestion  being  a  sign  of  defective  circulation  in 
the  larynx,  it  may  be  considered  grave  in  the  case  of  singers, 
as  they  are  liable  to  lose  their  voice,  and  especially  those 
who  are  husky  in  the  morning. 

Prognosis  is  generally  benign,  if  the  patient  is  prudent  and 
cautious. 

Diagnosis  is  usually  easy,  because  the  acute  catarrhal 
inflammation  of  the  vocal  mucous  membrane,  which  is 
somewhat  analogous  to  laryngeal  congestion,  presents 
characteristic  symptoms. 

Treatment. — The  sole  treatment  is  rest  of  the  organ — i.e., 
silence.  However,  when  the  congestion  is  slight  or  tran- 
sitory, a  very  hot  foot-bath,  mustard  poultice  at  the  nape  of 
the  neck,  with  some  drops  of  an  alcoholic  tincture  of  aconite 
root  suffice  to  dispel  it.  The  author  has  often  successfully 
ordered  the  following  : 

^  Tincture  of  aconite  (alcoholic) 
Bromide  of  potassium 
Compound  syrup  of  erysimum 
Cherry-laurel  water 
Infusion  of  lime  flowers   ... 

Two  or  three  spoonfuls  daily  in   a  warm  infusion  of  lime- 
tree  flowers. 

Sometimes  applications  of  cocainized  and  mentholated 
vaseline  are  sufficient  to  make  the  congestion  disappear. 

Laryngeal  haemorrhages  are  due  to  the  same  causes  as 
the  congestion.  There  is  only  a  difference  of  degree  between 
the  two  lesions.  Haemorrhages  occur,  over  and  above,  in 
neuropathic,  hsemophilic,  and  arthritic  patients,  specially 
in  those  affected  with  atrophic  rhino-pharyngo-laryngitis. 
They  have  been  observed  as  supplementary  haemorrhages  in 
women.     They  are  not  rare  in  malignant,  or  even  in  benign. 


25  drops 

n^Lxxv 

3  grammes 

gr-  45 

•■•     30 

5vii 

...     10 

oiiss 

...   120 

^iv 

172  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

tumours  of  the  larynx.  The  symptoms  are  those  of  con- 
gestion, but  more  intense,  and,  in  addition,  expectoration 
is  sanious  or  bloody.  The  laryngoscope  shows  signs  of  an 
intense  congestion  of  the  vocal  mucous  membrane,  some- 
times simple  vascular  arborescence,  sometimes  ecchymosis,  or 
even  true  blood  cysts  resulting  from  interstitial  hsemorrhages. 
The  latter  are  met  with  specially  in  singers,  teachers,  and 
others  after  straining  the  voice.  In  some  cases  laryngoscopy 
shows  clots  adherent  to  the  cords,  and  even  blood  exuding 
from  the  mucous  membrane. 

Diagnosis  is  generally  easy.  The  alterations  of  the  voice, 
and  the  lesions  observed,  determine  the  seat  of  the  bleeding. 

If  haemorrhage  is  superficial  it  stops  spontaneously,  but  if 
it  becomes  profuse,  it  may  be  checked  by  the  external  and 
internal  application  of  ice,  or  by  the  galvano-cautery,  or  by 
a  solution  of  adrenalized  cocaine. 

The  following  formula  is  recommended: 

J^  Solution  of  adrenalin  ( I  :  i.ooo)  I  {   ill  xv 

\         '       ^  -        I  gramme        .      ^ 
Hydrochlorate  of  cocaine  J  igr.  15 

Cherry-laurel  water  ...  ...     8  grammes  5ii 

Glycerine  (pure)      ...  ...  ...     2         ,,  n\^xxv 

Treatment  consists  in  checking  the  cause  of  the  con- 
gestive Onset.  In  some  cases  rest  of  the  organ,  slight 
saline  purgatives  ;  in  others,  ph5^sical  exercise,  hydrotherapy, 
or  antispasmodics,  will  produce  a  good  result.  It  is  well 
to  remember  that  a  solution  of  concentrated  cocaine  (i  :  5 
or  I  :  10)  does  not  produce  in  some  patients  anaesthesia  or 
vaso-constriction,  but,  on  the  contrary,  a  kind  of  vesication  of 
the  vocal  cords. 

Burns  of  the  Larynx. 

Isolated  burns  on  the  larynx  are  rare.  Their  symptoms 
are  respiratory  disturbances  through  acute  cedema,  and 
dysphagia.  The  epiglottis  and  the  arytenoid  region  are 
most  frequently  affected.  The  lesion  varies  from  the  appear- 
ance of  slight  erythema  with  œdematous  infiltration,  to  that 
of  necrosis  and  gangrene. 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     173 

Wounds  of  the  Larynx. 

Wounds  of  the  larynx  are  accidental  or  surgical.  The 
former  are  caused  by  sharp  cutting  objects  introduced 
into  the  larynx.  The  mucous  membrane  may  also  be 
ruptured  by  violent  coughing  or  retching. 

Locality. — -They  may  occur  in  the  whole  laryngo-tracheal 
tract,  but  are  more  frequent  on  the  thyro-hyoid  membrane 
and  on  the  trachea. 

Symptoms  vary  according  to  the  extent  and  locality  of  the 
wound. 

Broad  Wounds. — If  the  incision  is  transverse,  the 
lips  of  the  wound  will  be  more  or  less  apart,  according  to 
the  position  of  the  head,  and  whether  the  anterior  muscles 
of  the  neck  have  been  severed  or  not.  The  immediate  loss 
of  blood  is  always  alarming,  and  it  is  not  rare  to  see  the 
wounded  person  succumb  from  haemorrhage. 

The  condition  of  respiration  is  variable.  Sometimes 
expiration  produces,  as  it  were,  a  splashing  of  blood,  and 
inspiration  a  characteristic  whistling  sound.  If  the  trachea 
is  severed,  the  upper  portion  is  drawn  upwards,  and  the 
inferior  portion  disappears  downwards. 

Asphyxia  may  result  from  this  downward  retraction  of  the 
trachea,  from  the  flow  of  blood  into  the  bronchi,  or  from 
the  obstruction  of  the  larynx  by  partly  detached  portions 
floating  in  it,  or  by  the  object  itself,  that  caused  the  wound. 

The  voice  is  sometimes  unaffected,  but  as  a  rule  it  is  other- 
wise, especially  if  the  wound  reaches  the  thyro-hyoid  mem- 
brane, the  cords,  or  the  arytenoid  cartilages.  Likewise  if  one 
of  the  two  récurrents  is  affected,  muscular  disturbances  will 
be  produced  corresponding  to  the  mutilation. 

Disturbances  of  deglutition  vary  according  to  the  locality 
and  extent  of  the  lesion.  A  wound  at  the  level  of  the 
thyroid  cartilage  causes  an  acute  pain  during  the  upward 
movement  of  the  larynx.  If  the  thyro-hyoid  membrane  is 
cut,  the  food  may  penetrate  into  the  larynx.  Those  distur- 
bances are  consummated,  when  the  wound  implicates  the 
vocal  organ  and  the  pharynx. 


174  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

Narrow  Wounds.  —  In  this  case  subcutaneous  em- 
physema appears,  and  if  this  is  very  pronounced,  asphyxia 
ensues.  It  is  rare  that  considerable  hsemorrhage  takes  place, 
unless  a  vessel  of  some  importance  be  severed.  Infiltration 
of  air  and  blood  may  cause  compression  of  the  larynx,  and 
necessitate  immediate  intervention.  If  the  cords  have  not 
been  affected,  vocal  disturbances  are  nil  or  slight. 

Laryngoscopic  examination  shows  either  considerable  loss 
of  substance,  or  simply  ecchymosis  or  œdema  occupying  the 
wall  of  the  larynx,  the  trachea,  and  even  the  orifice  of  the 
oesophagus.  Darkish  characteristic  ecchymotic  lesions  are 
observed  in  cases  of  strangulation. 

Those  wounds  are  always  very  painful,  especially  on 
deglutition. 

Diagnosis. — In  dubious  cases  the  emphysema,  the  presence 
of  asphyxia,  and  subcutaneous  ecchymosis  afford  useful 
indications. 

Pathological  Anatomy. — The  state  of  the  internal  wound  is 
not  necessarily  determined  by  the  appearance  of  the  external 
wound  ;  for  example,  a  small  loss  of  substance  may  coincide 
with  a  severe  wound  of  the  larynx. 

Complications. — Those  wounds  may  be  complicated  by  the 
introduction  of  air  into  the  veins,  emphysema,  or  haemorrhage. 
Secondary  complications  consist  especially  in  abscesses 
and  gangrene.  Sometimes  the  disorganization  of  the  carti- 
lages of  the  larynx  is  so  great,  that  the  life  of  the  patient  can 
only  be  preserved  by  the  introduction  of  a  canula. 

Course. — The  edges  of  the  wound  being  irregular,  infection 
may  occur  in  spite  of  immediate  treatment.  Death  may 
ensue  from  hsemorrhage,  suppuration,  or  septicaemia.  As 
permanent  sequelae,  fistula,  and  laryngo  or  tracheal  stenosis 
may  occur. 

Treatment. — The  first  step  is  to  arrest  bleeding  by  con- 
striction or  ligature  of  the  bloodvessels  —  veins  as  well 
as  arteries  ;  then  antiseptic  cleansing  of  the  wound  should 
be  carried  out.  If  asphyxia  is  apprehended,  a  tracheal  canula 
should  be  introduced,  either  by  the  wound  or  through  an  arti- 
ficial opening.     The  application  of  Trendelenburg's  canula 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     175 

is  of  assistance.  The  torn  portions  of  the  muscles,  which 
have  no  chance  of  being  reunited,  and  which  might  induce 
gangrene,  should  be  cut  away.  In  order  to  avoid  emphysema, 
the  tracheal  opening  should  not  be  wholly  closed.  The 
deep  parts  should  be  sutured  with  catgut,  the  head  being 
placed  in  a  suitable  position,  and  antiseptic  treatment  applied 
according  to  the  requirements  of  the  case.  If  small  wounds 
exist,  with  emphysema,  scarification  should  be  made,  and  if 
need  be,  the  pretracheal  and  laryngeal  tissues  relaxed,  in 
order  to  prevent  the  diffusion  of  air  into  the  tissues. 


Fractures  of  the  Larynx. 

Etiology. — Those  fractures  are  very  rare,  because  the  larynx 
is  formed  of  cartilage  loosely  connected  with  the  neighbouring 
parts,  its  elasticity  enabling  it  to  escape.  The  ordinary  causes 
of  fracture  are  violent  pressure  on  both  sides  of  the  thyroid 
cartilage,  or  a  sudden  impact  anteriorly — e.g.,  with  the  hand 
or  foot,  or  a  carriage  wheel.  Fracture  of  the  larynx  is  rarely 
brought  about  by  hanging. 

PatJwgeny. — Fracture  of  the  framework  of  the  larynx  is 
produced  in  two  ways — by  crushing  or  by  divulsion.  The 
former  occurs  more  frequently,  when  the  larynx  is  injured 
anteriorly,  as  it  leans  against  the  vertebral  wall. 

Symptoms — -(i)  Physical  Signs. — If  the  fracture  has  occurred 
from  a  blow  or  violent  thrust,  the  neck  is  flattened,  owing  to 
the  giving  way  of  the  th3'roid  cartilage.  On  the  other  hand, 
if  the  fracture  is  due  to  bilateral  compression,  the  larynx  pro- 
jects. Those  symptoms  are  not  to  be  exclusively  relied  upon, 
as  swelling  may  conceal  them.  If  the  subject  has  a  slender 
neck,  with  a  pronounced  larynx,  the  fracture  may  be  felt  by 
the  finger  if  pressure  be  exercised  laterally.  The  larynx  is 
abnormally  mobile.  Some  authors  say,  that  they  have  felt 
crepitus,  but  this  is  not  easily  perceived.  Not  only  may  it 
be  confused  with  crepitation  of  a  normal  larynx,  but  it  is 
also  somewhat  dangerous  to  elicit. 

In  all  cases  where  crepitation  is  sought  for,  it  should  be 
differentiated  from   what  is  normally  produced  by  friction 


176  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

of  the   great    cornua    of  the    th3'roid   cartilage  against  the 
vertebral  column. 

Generally,  if  the  vocal  mucosa  has  become  involved,  a 
certain  degree  of  emphysema  supervenes,  localized  on  the 
neck,  or  extending  to  the  face  or  upper  portion  of  the  thorax. 
Laryngoscopic  examination  may  be  resorted  to,  and  con- 
firm the  result  of  external  examination.  Direct  examina- 
tion, if  practised  not  long  after  the  accident,  shows  a  more 
or  less  diffused  ecchymosis,  seated  not  only  on  the  vocal 
organ,  but  often  at  the  orifice  of  the  air-tracts  and  on  the 
pharyngeal  wall  and  trachea.  These  ecchymoses  may  be 
seen  exteriorly  under  the  skin,  which  assumes  a  purple  or 
reddish  colour. 

(2)  Functional  Symptoms. — The  first  symptom  is  spontaneous 
pain,  very  acute  at  the  outset,  abating  rapidly,  but  excited 
by  any  movement  of  the  neck,  or  by  touch. 

The  gravest  symptom  is  interference  with  respiration. 
Asphyxia  may  occur  even  immediately,  and  is  characterized 
by  cyanosis  of  the  face,  coldness  of  the  skin,  and  small 
pulse.  The  course  of  the  respiratory  disturbances  is  very 
variable.  They  may  be  very  considerable  at  the  outset,  or 
be  gradually  aggravated  by  swelling,  by  generalized  oedema, 
or  by  concomitant  emphysema.  Some  patients  have  been 
asphyxiated,  even  when  in  the  process  of  recovery,  either  by 
the  displacement  of  a  detached  fragment  or  by  dislocation 
of  the  arytenoid  cartilage. 

Vocal  disturbances  depend  on  the  alteration  of  the  vocal 
cords.  Deglutition  is  generally  painful.  The  expectoration 
is  usually  blood-streaked,  and  becomes  purulent  and  fetid. 

Diagnosis. — -The  existence  of  fractures  of  the  larynx  is 
sometimes  easily  diagnosed,  but  it  is  difficult  to  determine 
their  nature  by  the  functional  symptoms.  Laryngoscopy  and 
radiography  will  greatly  assist.  Blood-stained  expectora- 
tion, and  specially  infiltration  of  air  into  the  tissue,  are 
significant  symptoms. 

Pathological  Anatomy. — The  larynx  is  composed  of  four 
chief  parts — two  odd  (the  cricoid  and  the  thyroid)  and  one 
pair  (the  arytenoids). 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     177 

The  fracture  of  the  cricoid  may  be  situate  either  posteriorly, 
laterally,  or  anteriorly.  The  line  of  the  fracture  is  generally 
vertical  or  slightly  oblique  throughout  the  cartilage.  If  there 
is  only  one,  it  is  usually  posterior  ;  if  there  are  many,  they 
may  occupy  any  part  of  the  cricoid.  Fractures  of  the 
thyroid,  even  though  deep,  may  extend  throughout  its  whole 
length.  They  may  be  rectilinear,  vertical  or  oblique,  or  like 
an  S.  Complete  fractures  are  the  most  common,  but  their 
site  is  variable.  Sometimes  the  horns  are  detached  ;  some, 
times  one  of  the  laminae  has  been  divided. 

There  may  be  only  one  lesion,  but  often  several  com- 
minuted fractures  are  seen,  when  the  cartilage  is  crushed. 
Simple  fractures  of  the  thyroid  are  of  a  fairly  regular  type. 

The  soft  parts  are  affected  in  different  ways.  The  peri- 
chondrium is  sometimes  unaffected,  but  at  other  times  it  may 
be  injured  internally  and  externally.  The  laryngeal  mucous 
membrane  and  muscles  may  be  contused  and  even  lacerated, 
this  favouring  the  occurrence  of  emphysema.  If  the  wound 
is  the  result  of  great  violence,  the  hyoid,  trachea,  oesophagus, 
inferior  maxilla,  and  the  clavicle  may  be  implicated. 

Course — Prognosis. — The  traumatism  may  heal  in  two  ways. 
If  the  framework  of  the  larynx  is  still  cartilaginous,  the 
fragments  are  united  by  new  cartilaginous  or  osseous  tissue  ; 
but  should  the  cartilage  be  ossified,  healing  is  similar  to  that 
of  long  bones.  If  suppuration  occurs  in  the  region  of  the 
wound,  consolidation  may  be  retarded  or  entirely  prevented. 
If  the  evacuation  of  the  pus  is  rapid,  reparation  is  simply 
impeded  ;  if,  on  the  other  hand,  the  purulent  process  persists, 
caries  and  necrosis  may  ensue. 

Prognosis  varies  according  to  the  importance  of  the  lesion, 
its  extent,  and  the  time  of  intervention.  Generally  it  is 
extremely  grave.  Twelve  to  fifteen  per  cent,  of  the  patients 
survive.  Lesions  of  the  cricoid  are  the  gravest,  as  they 
produce  rapid  asphyxia.  When  healing  occurs,  prognosis 
is  not  always  favourable,  because  the  wound  may  result  in 
stenosis,  and  necessitate  the  use  of  a  permanent  canula. 

Treatment. — The  greatest  danger  being  asphyxia,  the  sole 
effective  treatment  is  tracheotomy,  especially  when  the  glottic 

12 


178  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

orifice  is  stenosed,   or  if  defective   union    has  taken    place, 
interfering  with  respiration. 

Acute  Catarrhal  Laryngitis. 

An  acute  catarrh  of  the  laryngeal  mucous  membrane. 

Etiology. — The  chief  causes  are  chills  acting  directly  on  the 
neck,  or  indirectly — e.g.,  cold  feet,  etc. 

Those  acute  inflammations  are  frequent  in  people  accus- 
tomed to  use  mufflers,  respirators,  or  in  those  exposed  to  irri- 
tating vapours,  such  as  tobacco,  the  drinking  of  hot  liquids,  etc. 

Laryngitis  is  consequent  on  coryza,  acute  angina  or 
tracheitis,  alcoholic  or  sexual  excess.  It  often  occurs  at  the 
beginning  of  certain  eruptive  fevers,  as  measles,  scarlatina, 
etc.  It  is  frequent  in  people  affected  by  rheumatism  or 
living  a  sedentary  life. 

Symptoms. — General  S3'mptoms  are  slightty  pronounced  or 
even  wanting.  Functional  S3'mptoms,  on  the  contrary,  are 
very  important.  They  are  characterized  by  a  feeling  of  heat 
in  the  throat. 

During  respiration  the  patient  experiences  a  burning 
sensation  from  the  cold  air  impinging  on  the  laryngeal 
mucosa,  so  that  he  breathes  through  the  nose.  The  cough 
is  dry,  short,  and  sometimes  spasmodic,  usually  with  little 
or  no  pain,  sometimes  accompanied  by  painful  racking. 

Secretion  is  absent  at  the  beginning,  but  appears  when  the 
inflrammation  has  reached  the  trachea,  and  is  then  viscous 
or  purulent  and  thick,  being  sometimes  in  acute  forms 
streaked  with  blood.  The  voice  is  slightly  affected,  if  the 
irritation  is  in  the  vestibule  of  the  larynx  ;  on  the  contrary, 
it  becomes  dull,  raucous,  or  aphonic,  if  the  inflammation 
affects  the  cords. 

In  light  forms  respiration  is  not  interfered  with.  Glottic 
spasm  is  characteristic  of  the  subglottic  form  particular  to 
children. 

Examination  of  the  Larynx. — At  the  beginning  a  diffuse 
hyperaemia  of  the  whole  vocal  mucosa  is  observed,  not  only 
on  the  posterior  surface  of  the  operculum  of  the  glottis,  but 
also  on  the  ventricular  bands,  arytenoids,  and  the  true  cords. 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     179 

The  latter  are  of  a  more  or  less  intense  rosy  colour.  Their 
surfaces  appear  uneven  and  rough.  In  certain  cases  the  redness 
is  not  diffused,  but  occurs  in  patches.  At  other  times  the  vocal 
cords,  especially  in  cases  of  alcoholism,  are  somewhat  swollen. 
Some  greyish  opalescent  erosions,  surrounded  by  a  red 
inflamed   reticulum,    and  even    superficial   ulcerations,   may 


Fig.  93. — Sterilizable  Aseptic  Inhaler,  with  Double  Set  of  Valves. 

(Dr.  Moure.) 


be  observed  occupying  the  posterior  part  of  the  cords  on 
their  inner  edge,  their  superior  surface,  or  the  free  edge 
towards  the  anterior  third.  The  author  has  seen  in  some 
arthritic  people  true  rhagades,  with  thickening  of  the  inter- 
arytenoid  mucous  membrane,  which  then  appeared  mam- 
millated,  of  a  bright  red  colour,  and  often  covered  with  viscous 

12 — 2 


i8o  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

secretion.  The  thyro-arytenoideus  and  the  ary-arytenoideus 
muscles  may  be  affected,  and  so  produce  loss  of  parallelism  of 
the  cords  during  phonation.  Those  muscles  are  specially 
liable  to  be  attacked  on  account  of  their  exposed  position. 

Course  and  Duration. — This  disease  has  usually  a  regular 
course.  It  attains  its  maximum  intensity  on  the  second  or 
third  day,  and  gradually  diminishes  and  disappears  between 
eight  and  twelve  days,  unless  the  disease  becomes  chronic. 
In  smokers  and  singers  laryngitis  may  last  for  weeks. 

Diagnosis  is  usually  easy.  Anamnesis,  subjective  and 
objective  symptoms,  render  diagnosis  precise,  even  differen- 
tiating the  disease  from  laryngitis  caused  by  influenza. 

Prognosis  is  benign  in  the  case  of  adults,  a  cure  being  the 
rule  ;    but,  in    singers    and   speakers,  the  voice    may  be    so 


Fig.  94. — KiLLiAx's  Laryngeal  Cottox-wool  Holder. 


changed,  as  to  hinder  them  for  a  long  time  from  performing 
their  work. 

Treatment. — In  grave  cases  absolute  rest  of  the  organ  is 
imperative.  The  patient  should  keep  indoors  at  a  tempera- 
ture of  15  to  20°  C.  Beverages  and  inhalations  and  warm 
compresses  are  recommended.  Emollient  inhalations  may 
be  prescribed,  as  follows  : 

1^  Menthol  powder  ) 

■n  1  r -n  -     ...  aa       5  grammes        aa  gr.  75 

Balsam  of  Peru    1  -^  ^  &     /  j 

Tincture  of  eucalyptus       ...       250        ,,  3viii 

Those  inhalations  are  made  once  or  twice  daily  for  three 
or  five  minutes. 

It  is  preferable  not  to  use  too  hot  water,  which,  from 
excessive  evaporation,  might  cause  coughing.  Usually  the 
patient  soon  becomes  accustomed  to  this  form  of  medication, 
and  can   use  even  boiling  water.     He  is  recommended  to 


I  gramme 

liLxv 

2  grammes 

gr-30 

4 

gr.  60 

30 

5vii 

10 

oiiss 

120 

3iv 

DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     181 

employ  a  cone  of  thickish  paper  placed  above  the   boiling 
water,  so  as  to  inhale  through  the  nose  and  mouth.     The 
eyes  should  be  kept  out  of  the  range  of  the  mentholized  steam. 
A  satisfactory  result  may  be  obtained  from — 

1^  Tincture  of  aconite  root  (alcohol)  ... 
Bromide  of  potassium  or  salicylate 

of  soda 
Benzoate  of  soda 
Syrup  of  krameria 
Cherry-laurel  water 
Lime-tree  flower  decoction 
Three  or  four  tablespoonfuls  daily  in  a  warm  infusion. 

Local  intervention  must  be  avoided  during  the  acute 
period  of  the  laryngitis.  If  the  latter  occurs  at  the  period  of 
menstruation,  no  local  application  should  be  made  as  long 
as  the  duration  of  the  flow  continues. 

When  the  acute  phenomena  are  almost  over — say  in  about 
ten  or  twelve  days — the  larynx  may  be  painted  with  a 
solution  of  zinc  of  chloride  (i  :  50  or  i  :  100). 

If  the  laryngitis  frequently  recurs,  the  nasal  fossae,  the 
accessory  cavities,  or  the  naso-pharynx  should  be  examined, 
to  find  out  if  a  cause  exists  for  the  recurrence. 

Rupture  of  the  Thyro-arytenoideus. 

Etiology. — The  usual  cause  of  those  ruptures,  which  are 
always  unilateral,  is  excessive  vocal  effort  during  fatigue  or 
huskiness  of  the  voice. 

Symptoms. — The  chief  symptom  is  the  suddenness  of  the 
attack,  the  patient  feeling  all  at  once  an  acute  pain  in  one 
side  of  the  larynx,  followed  by  dulness  of  the  voice.  Some- 
times he  may  be  unable  to  speak.  The  pain  disappears 
quickly,  but  the  vocal  disturbances  remain  as  pronounced 
as  ever. 

Laryngoscopic  examination,  if  made  early,  shows  that  the 
affected  cord  is  the  seat  of  a  violent  haemorrhage,  and  is 
swollen  to  three  or  four  times  its  normal  bulk.     Its  entire 


1 82  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

surface  is  irregular  and  congested,  resembling  the  lesion 
described  as  chorditis  tuberosa.  The  ventricular  bands  and 
the  subglottic  region  are  intact.  Adduction  of  the  vocal 
cords  is  unaffected,  and  the  lesion  disappears  in  a  month  at 
least.  The  cord  gradually  resumes  its  normal  volume,  but 
remains  red,  finally  becoming  greyish  and  dull. 

In  the  case  of  a  singer,  the  voice  may  remain  broken, 
become  fatigued,  and  may  lose  something  of  its  timbre. 

Speakers  may,  after  several  months'  rest  and  treatment, 
recover. 

Prognosis  is  grave  only  in  singers  and  alcoholic  patients, 
or  in  those  who  are  compelled  to  use  their  voice  during  the 
illness. 

Pathological  Anatomy. — The  author  thinks,  that  the  milder 
forms  are  due  to  the  rupture  of  a  vein,  whereas  the  graver 
forms  are  caused  by  the  rupture  of  some  of  the  fibres  of  the 
thyro-arytenoideus. 

Diagnosis  rests  on  the  sudden  appearance  of  the  affection. 
In  grave  cases  after  resolution  a  small  notch  is  seen  on  the 
affected  cord. 

Treatment. — Rest  to  the  organ  is  the  main  consideration. 
Hot  fomentations  and  inhalations  will  be  of  good  service. 
Some  time  after  the  accident  the  vocal  cord  may  be  lightly 
brushed  with  zinc  chloride  or  nitrate  of  siver  (i  :  50  or 
1 :  30).  At  the  second  period — i.e.,  fifteen  to  twenty-five 
days  after  the  accident — inhalations  should  be  replaced  by 
the  spray. 

Epiglottitis. 

An  acute  inflammation  of  the  laryngeal  mucous  membrane 
restricted  to  the  epiglottis. 

Etiology. — In  addition  to  the  usual  causes  of  acute  laryn- 
gitis, ingestion  of  too  hot,  caustic,  or  irritating  liquids  (soda, 
potash,  etc.)  may  produce  this  lesion. 

Symptoms. — The  functional  symptoms  are  much  more 
intense  than  in  simple  laryngitis.  The  sensation  of  the 
presence  of  a  foreign  body  in  the  throat  is  rapidly  felt. 
Pressure  on  the  larynx  is  painful,  as  are  the  movements  of 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     183 

deglutition  and  phonation.  In  grave  cases  pain  extends  to 
the  ears.  Respiration  is  not  interfered  with,  unless  the 
epiglottis  is  so  markedly  congested  and  œdematous,  as  to 
obstruct  the  laryngeal  orifice.  Laryngoscopy  shows  generally 
on  the  lingual  surface  of  the  epiglottis  a  red  or  whitish  red 
globular  projection.  Its  surface  is  irregular,  slightly  granular, 
and  in  such  cases  the  pre-epiglottic  tonsil  is  often  involved. 

Diagnosis. ^This  lesion  might  be  mistaken  for  one  pro- 
duced by  a  traumatism — e.g.,  a  needle,  etc. — but  the  appear- 
ance and  origin  of  the  lesion  are  sufficient  to  make  a  clear 
diagnosis. 

Treatment. — This  is  the  same  as  in  laryngitis,  but  in  this 
case  gargles  are.  of  assistance.  The  patient  should  pro- 
nounce the  syllables  '  gloo-gloo,'  so  that  the  fluid  may  reach 
the  epiglottis.  Sedative  remedies,  the  formulas  of  which 
have  been  already  given,  are  recommended.  If  there  be 
much  oedema  present,  the  epiglottis  should  be  scarified  by 
means  of  the  galvano-cautery,  or  by  cutting  a  part  of  its 
surface  with  Moritz-Schmidt's  or  Gougenheim's  forceps. 
If  respiration  is  embarrassed,  tracheotomy  should  be  per- 
formed. 

Aphthous  Laryngitis. 

Aphthae  are  fairly  common  in  the  mouth,  on  the  gums, 
tongue,  lips,  cheeks,  and  even  on  the  uvula  and  soft  palate. 
In  some  cases  they  have  been  observed  on  the  tonsils,  the 
pillars,  and  even  on  the  mucous  membrane  of  the  rest  of  the 
digestive  tract. 

Etiology. — This  eruption  is  similar  to  aphthous  stomatitis, 
and  is  caused  by  the  ingestion  of  spiced  or  unsound  food, 
tainted  fish,  etc.  The  larynx  is  infected  through  auto- 
inoculation,  the  saliva  being  the  medium  of  infection. 

Symptoms. — The  chief  symptom  is  intense  pain  on  degluti- 
tion, most  marked  with  the  saliva  or  spiced  food.  In  children 
the  pain  is  so  acute,  that  they  refuse  to  take  food.  Usually  no 
general  symptoms  exist.  The  lesion  of  the  larynx  is  frequently 
accompanied  by  similar  aphthae  in  the  buccal  cavity.  The 
aphthae,  two  or  three  at  most,  present  the  usual  appearance. 


i84  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

At  the  outset  they  are  greyish  ovular  spots,  surrounded  b}^ 
a  very  red  border,  without  peripheral  infiltration.  They 
generally  occur  on  the  edges  of  the  epiglottis,  the  glosso- 
epiglottic  folds,  and  even  the  aryepiglottic  folds  or  arytenoid 
region. 

Diagnosis, — The  mucous  patches  of  syphilitic  laryngitis 
are  equally  superficial  and  opaline,  but  much  more  irregular 
in  their  form,  and,  above  all,  much  less  painful.  Herpes  is 
differentiated  by  a  violent  attack  of  fever,  larger,  more 
erosive,  and  more  numerous  spots.  Moreover,  it  usually 
develops  at  the  same  time  on  the  soft  palate,  the  pillars, 
and  often  even  on  the  lips.  Pemphigus,  presenting  sharp 
characteristics,  can  hardly  be  confounded  with  aphthous 
laryngitis. 

Treatment  consists  in  carefully  avoiding  all  irritating  food. 
An  alkaline  diet  should  be  prescribed.  If  dysphagia  is  too 
intense,  relief  may  be  derived  by  applying  to  the  eroded  parts 
some  fused  nitrate  of  silver  on  the  porte-caustique. 

Dysphagia  may  be  modified  by  alkaline  and  cocainized 
gargles,  or  by  the  insufflation  of  orthoform. 

Acute  Œdematous   Laryngitis. 

Primary  Œdema — Etiology. — The  chief  cause  is  cold. 
Excessive  use  of  the  voice,  ingestion  of  boiling  liquids,  and 
the  introduction  of  foreign  bodies,  also  produce  this  inflam- 
matory lesion.  External  traumatisms,  operations  on  the 
larynx  from  without,  applications  of  concentrated  solutions 
of  cocaine  or  adrenaline,  or  even  absorption  of  certain 
remedies,  such  as  iodide  of  potassium,  may  produce  acute 
serous  suffusions  of  the  larynx.  This  affection  appears  to  be 
more  frequent  in  men,  and  at  middle  age. 

Secondary  Œdema  may  be  consequent  on  lesions 
of  the  neighbouring  parts  or  of  distant  organs.  It  appears 
also  after  acute  angina,  and  tuberculous  or  syphilitic  ulcera- 
tions of  the  larynx.  It  often  accompanies  Ludwig's  angina, 
furunculosis,  and  anthrax  in  this  region,  and  is  observed  in 
certain  inflammations  of  the  vertebral  column,  and  in 
aneurisms  of  the  aorta. 


DISEASES  AXD  TRAUMATISMS  OF  THE  LARYXX     185 

Erysipelas  appears  fairh"  often  in  the  larynx.  Œdema  is 
met  with  as  a  complication  of  laryngitis,  due  to  influenza, 
also  in  Bright's  disease,  p5'£emia,  ulcerative  endocarditis,  and 
even  in  some  lesions  of  the  right  side  of  the  heart. 

Symptoms. — Acute  œdema  of  the  larynx  gives  rise  to  many 
s\-mptoms.  The  most  manifest  are  disturbances  of  the  voice, 
which  in  most  cases  is  husky,  without  resonance,  or  even 
aphonia.  Pain  is  absent,  except  for  the  sensation  of  a 
foreign  body.  Deglutition  is  sometimes  interfered  with. 
The  most  prominent  symptom  consists  in  respiratory  dis- 
turbance. Sibilant,  or  at  least  loud  inspiration,  with  free 
expiration,  occurs  only  when  the  œdema  is  seated  in  the 
vestibule  of  the  larynx,  and  particularly  in  the  aryepiglottic 
folds  and  in  the  epiglottis  itself.  Inspiration  and  expiration 
are  usually  affected,  producing,  as  it  were,  guttural  snoring. 
If  the  serous  exudation  is  very  pronounced  and  rapid,  attacks 
of  choking  frequently  occur.  Only  then  do  we  have  the 
symptoms  of  glottic  œdema  :  the  patient  cyanosed,  his  face 
livid  or  blackish,  e3'es  haggard,  sits  up  in  his  bed  struggling 
for  breath.  This  lesion  is,  however,  exceptional,  only  occur- 
ring when  the  œdema  has  been  produced  very  rapidly,  and 
has  developed  to  an  excessive  extent,  closing  the  laryngeal 
aperture.  General  symptoms,  as  fever,  headache,  etc.,  are 
absolutely  wanting. 

Examination  shows  a  partial  or  total  deformity  of  the 
epiglottis,  which  appears  rounded  and  sausage-like,  and  may 
become  sufficiently  large  to  almost  close  the  aperture  of  the 
larynx.  If  the  ar}epiglottic  folds  alone  are  affected,  as 
usually  occurs,  they  appear  as  two  pyriform  slightly  rounded 
masses,  with  smooth  gre\-ish  surfaces  resembling  fish  sounds, 
and  are  of  various  sizes  up  to  the  dimension  of  the  thumb, 
and  move  with  each  effort  of  inspiration. 

According  to  Gougenheim,  however,  respirator}-  difficulty 
is  due,  not  to  the  aspiration  of  those  swollen  bodies,  but 
rather  to  the  immobility  of  the  crico-arytenoid  articulation. 

Sometimes  the  œdema  is  unilateral,  and  in  some  rare  cases 
the  surface,  instead  of  being  greyish,  is  of  a  uniform  bright- 
red  colour. 


1 86 


DISEASES  OF  THE  PHARYNX  AND  LARYNX 


If  the  œdema  has  extended  to  the  ventricular  bands,  which 
is  very  rare,  the  latter  appear  as  two  reddish  folds,  of  a  deeper 
coloration  than  the  aryepiglottic  folds,  and  partly  cover  the 
vocal  cords. 

The  ventricular  bands,  although  healthy,  may  appear 
swollen,  owing  to  the  efforts  of  the  patient  to  speak.  In 
such  a  case  the  condition  of  this  organ  can  only  be  seen 
during  respiration. 

When  serous  infiltration  occurs  on  the  vocal  cords,  they 
assume  a  dirty  grey  colloid  appearance  ;  their  bulk  is  double 
or  treble  the  normal  size,  and  they  come  in  contact  anteriorly. 
In  such  a  case  the  affection  may  invade  even  the  subglottic 


Fig.  95.— Acute  Œdema  of  the  Aryepiglottic  Folds.     (Moure.) 

I,  2,  Œdematous  aryepiglottic  folds  ;  3,  epiglottis  ;  4,  ventricle  ; 
5,  ventricular  band  ;  6,  vocal  cord  ;  7,  trachea. 

region,  more  or  less  immobilize  the  arytenoids,  and  thus 
considerably  interfere  with  respiration. 

Course. — The  course  of  acute  œdematous  laryngitis  is  very 
variable.  Sometimes  it  is  extraordinarily  rapid.  At  other 
times  the  œdema  progresses  by  successive  attacks,  and  lasts 
from  eight  to  fifteen  days,  unless  complications  occur.  As  a 
rule,  the  disease  terminates  by  resolution  ;  at  other  times  by 
an  abscess  or  phlegmon.     This  is  rare. 

Prognosis  is  serious,  because  a  fatal  issue  is  always  to  be 
dreaded,  if  the  inflammation  cannot  be  stopped,  or  if  it 
occurs  so  rapidly,  that  immediate  intervention  is  impossible. 
If,  on  the  contrary,  the  affection  is  slow,  the  patient  may 
bear  a  considerable  amount  of  constriction. 


DISEA SES  AND  TRA  UMA TISMS  OF  THE  LA R YNX     1 8 7 

Pathological  Anatomy. — The  seat  of  the  serous  exudation 
is  variable.  It  occupies  preferably  the  parts  of  the  larynx 
where  the  cellular  tissue  is  loose. 

Diagnosis  has  been  simplified  by  laryngoscopy,  which 
reveals  the  nature  of  the  disease,  and  differentiates  it  at  once 
from  paralysis  or  tumour.  The  acute  affection  may  be  dis- 
tinguished from  a  secondary  œdema  by  the  course  of  the 
disease,  and,  if  need  be,  by  interrogation  of  the  patient. 
Diphtheria  is  easily  recognizable  by  false  membrane  in  the 
pharynx  or  larynx. 

Treatment  consists  in  prescribing  saline  laxatives,  as 
sulphate    of   soda   or    magnesia.     If  the  patient  is   strong. 


Fig.  96. — Moritz-Schmidt's  Punch  Forceps. 


leeches  may  be  applied  to  each  side  of  the  larynx.  Warm 
poultices,  foot-baths  with  mustard,  ice  administered  internally 
or  externally,  cold  drinks,  and  aromatic  or  antiseptic  in- 
halations, are  also  excellent  remedies.  Subcutaneous  injec- 
tions of  pilocarpin  may  be  tried,  or  spraying  locally  with 
cocaine  (i  :  10)  or  adrenalin  (i  :  5,000  or  i  :  10,000).  When 
possible,  local  scarification,  or,  better  still,  the  excision  of 
œdematized  mucous  membrane,  should  be  practised.  If 
those  remedies  fail,  and  the  life  of  the  patient  is  en- 
dangered, tracheotomy  should  be  resorted  to.  Intubation 
of  the  glottis  is  a  difficult  and  dangerous  operation.  More- 
over, if  the  patient  has  an  onset  of  cough,  the  tube  may  be 
displaced  and  cause  death.     While  performing  tracheotomy, 


iS8 


DISEASES  OF  THE  PHARYNX  AND  LARYNX 


syncope  may  take  place,  especially  if  the  patient  has  had  for 
some  time  difficulty  in  breathing,  or  if  he  is  in  the  crisis  of 
asphyxia  {asphyxie  blanche)  at  the  time  of  operation.  In 
such  cases  the  operation  must  be  continued  without  fear  and 
rapidly.  Then,  as  soon  as  the  canula  is  in  position,  the 
trachea  should  be  tickled  with  a  feather,  or  artificial  respira- 
tion practised.  In  the  case  of  children,  the  canula  should 
not  be  removed  before  laryngoscopic  examination  has  shown, 
that  the  larynx  has  resumed  its  normal  permeability. 


Fig.  97. — Dr.  Hering's  Instruments  for  Curetting  and  Opening 
OF  Abscesses  of  the  Larynx. 

G,  H,  Bistouries  ;  I,  J,  K,  Curettes. 


Acute  Infantile  Laryngitis. 

Stridulant  and  Inflammatory  Forms. 

Etiology. — Laryngismus  stridulus  is  observed  specially  in 
children  from  two  to  seven  years  of  age,  and  is  still  known 
as  false  croup.  It  is  due  to  dentition,  the  presence  of  in- 
testinal worms,  naso-pharyngeal  lesions,  stomachic  troubles, 
and  eruptive  fevers.  Dr.  Ruault  thinks,  that  heredity  has 
something  to  do  with  the  etiology  of  this  disease,  the  real 
cause  of  which  is  the  narrowness  of  the  glottic  aperture  and 
the  peculiar  sensibility  of  the  laryngeal  mucous  membrane. 

Symptoms. — It  appears  in  two  distinct  forms.  The  first 
begins    with     a    slight    malaise    and    huskiness    occurring 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     189 

during  the  daytime  or  towards  the  evening,  but  abruptly 
during  the  night,  between  eleven  and  one  o'clock.  The 
child  wakens  and  breathes  with  difficulty,  gasping  for 
breath.  His  face  is  congested,  and  his  eyes  project,  ex- 
pressive of  fear  or  anguish.  Breathing  is  of  a  sibilant  and 
stridulous  nature,  and  the  cough  is  sonorous  and  croup-like. 
In  many  cases  the  cough  seems  to  be  very  dry.  The  onset 
lasts  for  some  minutes,  or  even  for  quarter  of  an  hour  or  half 
an  hour,  and  may  occur  several  times  in  a  night.  The  child 
sleeps  again,  and  wakens  the  morning  after  quite  gay  and 
happy.   Sometimes  the  voice  may  remain  husky  for  some  days. 

The  diagnosis  between  simple  laryngeal  spasm  and  acute 
infantile  catarrhal  laryngitis  is  based  on  the  functional 
symptoms,  which  follow  the  attack.  Frequently,  in  children 
predisposed  to  laryngismus  stridulus,  there  is  observed  the 
evening  before  some  malaise  and  slight  huskiness,  a  true 
catarrhal  laryngitis,  which  becomes  aggravated  during  the 
night,  and  is  accompanied  by  characteristic  spasms.  In  other 
cases  snuffling  {enchifrènenient)  exists  in  a  more  or  less  marked 
form,  and  the  child  is  not  so  quiet  as  usual  during  sleep.  He 
breathes  with  difficulty  through  the  nose,  and  then  wakens 
with  a  start,  a  victim  to  those  suffocative  spasms.  Simple  acute 
inflammatory  laryngitis  begins  with  slight  fever  and  catarrhal 
symptoms.  Only  after  two  or  three  days  do  the  attacks  appear, 
which  may  even  occur  in  the  daytime,  but  in  an  attenuated 
form.  The  crises  of  suffocation  are  longer  than  in  a  simple 
nocturnal  spasm.  Anguish  and  dyspnœa  are  more  pro- 
nounced and  persistent,  the  pulse  is  frequent,  the  face  con- 
gested and  covered  with  perspiration  ;  the  voice  remains 
feeble  and  low.  If  the  child  can  speak,  he  complains  of 
burning  and  tingling  sensations  in  the  throat  at  the  level  of 
the  larynx.  The  affection  lasts  for  eight  or  ten  days,  then 
the  cough  becomes  thick,  owing  to  expectoration,  or  at  least 
laryngo-tracheal  secretion.  In  graver  cases  of  laryngitis 
the  crisis  of  suffocation  at  the  onset  of  the  disease  persists 
violently  and  continuously,  and  the  breathing  is  stertorous 
and  laboured. 

At  every  moment  the  child  seems  on  the  point  of  being 


I90  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

asphyxiated.  He  is  voiceless  and  covered  with  perspiration. 
This  grave  condition  continues  from  twenty-four  to  forty- 
eight  hours,  and  even  beyond  that,  necessitating  tracheotomy 
or  temporary  intubation  of  the  larynx.  This  must  be  done 
without  hesitation,  otherwise  death  may  occur. 

Laryngoscopy  in  the  case  of  a  simple  spasmodic  laryngitis 
shows  a  mere  redness  of  the  laryngeal  vestibule  and  of  the 
vocal  mucosa. 

On  the  contrary,  in  acute  suffocative  laryngitis,  there  are 
seen  not  only  diffuse  hypergemia,  but  a  true  tumefaction  of 
the  subglottic  mucosa,  which  forms  beneath  the  red  inflamed 
cords  a  projecting  fold  overlapping  their  free  edges. 

To  these  material  lesions  is  added  a  spasmodic  condition, 
which  fixes  the  arytenoids  in  a  medial  position  and  aggra- 
vates dyspnœa.  As  soon  as  the  muscular  spasm  gives  way 
respiratory  disturbances  slowly  disappear,  although  the  in- 
filtration persists.  Bacteriological  examination  sometimes 
reveals  the  existence  of  the  Loeffler  bacilli,  but  is  usually 
negative.  Adenoiditis  frequently  accompanies  this  form  of 
laryngitis. 

Mechanismof  the  Attack. — According  to  Nyemeyer  and  Morell 
Mackenzie,  dyspnoea  is  due  to  accumulation  in  the  larynx  of 
secretions,  drying  up  and  narrowing  the  glottic  orifice.  Ac- 
cording to  Krisabert  and  Peters,  it  is  in  consequence  of  prior 
respiratory  disturbances,  preventing  complete  oxygenation 
from  taking  place.  Ruault  is  of  opinion,  that  those  attacks 
are  due  to  crises  of  glottic  and  tracheo-bronchic  spasm,  pro- 
duced by  local  irritation  of  the  laryngeal  mucosa.  If  they 
occur  specially  during  the  night,  according  to  him,  it  is 
owing  to  the  congestion  of  the  parts  being  increased  by 
decubitus.  The  author  is  inclined  to  think,  that  nasal  catarrh, 
compelling  the  child  to  breathe  through  the  mouth,  causes 
not  only  the  dryness  of  the  pharyngeal  cavity,  but  also  the 
laryngeal  spasm.  The  fact  is  often  observed  in  adults  after 
tumefaction  or  irritation  of  the  pituitary  mucosa.  Besides, 
the  pathogeny  of  the  affection  varies  according  to  the  form 
of  the  malady — whether  violent  laryngeal  spasm,  simple  or 
subglottic  true  inflammatory  laryngitis,  with  redness,  swell- 


DISEASES  AXD  TRAUMATISMS  OF  THE  LARYNX     191 

ing,  infiltration,  and  immobility  of  the  ar5^tenoids.  The 
existence  of  voluminous  adenoid  vegetations  certainlv  gives 
rise  to  stridulent  onsets. 

Course,  Diivation,  and  Tcrniination. — The  course  of  laryn- 
gismus stridulus  is  quite  irregular.  The  disease  may  occur 
once  or  twice  and  then  disappear  entireh^  In  other  cases 
the  child  remains  for  several  years  subject  to  those  crises, 
which  are  renewed  on  the  least  cause.  Ver}-  often  it  dis- 
appears after  the  removal  of  adenoid  vegetations.  Subglottic 
laryngitis  progresses  as  an  acute  catarrhal  inflammation, 
Ver}^  often  the  nocturnal  spasm  is  the  first  symptom  of  a 
graver  affection  of  the  respiratory  tract — bronchitis  or 
broncho-pneumonia.  Apart  from  ver}-  rare  cases  a  cure 
results. 

On  the  other  hand,  asphyxia  ma}-  occur  in  the  true  inflam- 
matory forms.  Death  then  ensues  from  syncope  or  increasing 
d3^spnœa. 

Diagnosis  is  easily  made.  The  occurrence  of  the  onset,  its 
abruptness,  its  manner  of  disappearing,  and  finally  the  age 
of  the  child,  help  to  determine  the  nature  of  the  disease. 
Laryngoscopy  alone  shows,  whether  it  is  a  case  of  a  spasmodic 
attack  due  to  an  inflammation  of  the  vocal  mucosa.  The 
persistence  of  the  d}"spncea  after  the  first  onset,  the 
stertorous  and  laboured  breathing  during  inspiration  and  ex- 
piration, with  or  without  alteration  of  the  voice  in  the  absence 
of  false  membrane  or  adenoiditis,  would  point  to  infraglottic 
laryngitis. 

The  introduction  of  a  foreign  body  into  the  air  tract  may 
resemble  a  crisis  of  grave  laryngitis.  Should  interrogation 
and  examination  of  the  patient  fail,  radiographv  would  clear 
up  the  diagnosis.  Moreover,  the  attack  would  more  likelv 
occur  during  the  dav. 

Treatment. — In  a  crisis  of  laryngismus  stridulus  a  sponge 
well  soaked  with  warm  water  should  be  applied  to  the  front  of 
the  neck,  and  revulsion  towards  the  lower  extremities  made. 
If  the  child  is  reasonable,  he  may  be  commanded  to  hold  m 
his  breath,  and  then  breathe  gently  through  the  nose.  This 
is  a  fairly  sure  and  rapid  way  of  alleviating  spasm.      Steam, 


192  DISEASES  OF  THE  PHARYXX  AXD  LARYNX 

slightly  mixed  with  tincture  of  mentholated  eucalyptus  and 
carbolic  acid,  also  produces  relief.  After  the  crisis  the  patient 
may  be  treated  as  in  simple  catarrhal  laryngitis.  In  many 
cases  introduction  of  powders  containing  cocaine,  or  prefer- 
ably of  cocainized  vaseline,  into  the  nose,  will  stop  nasal 
turgescence.     The  following  formula  may  be  employed  : 

l]c   Hydrochloride  of            5  to  15  centigrammes  gr.  3  to  g 
cocaine                        (according  to  the  age  of 

the  child) 

Powdered  menthol           5  to  10  centigrammes  gr.  3  to  6 

Boric  acid               ...         i  to  2  grammes  ôi  to  ii 

\'aseline      ...          ...      15  grammes  sii 

Put  a  pellet  of  this,  the  size  of  a  pea,  in  each  nostril,  morning 
and  evening,  and  let  the  patient  inhale  strongly. 

If  those  crises  are  due  to  a  known  cause,  as  dentition, 
intestinal  worms,  adenoid  vegetations,  those  lesions  must 
be  first  treated.  Finally,  in  grave  cases  recourse  should  be 
had  to  artificial  respiration,  inhalation  of  oxygen,  and  even 
to  tracheotomy  ;   but  intubation,  if  possible,  is  preferable. 

Influenzal  Laryngitis. 

Laryngeal  complications  developing  in  the  course  of  the 
general  disease  known  as  la  grippe  or  influenza. 

Etiology. — Influenza  or  la  grippe  seems  to  develop  prefer- 
ablv  in  cold  and  wet  weather,  but  appears  in  all  climates  and 
at  all  seasons. 

Symptoms. — Local  symptoms  vary,  according  as  the  malady 
presents  catarrhal,  infiltro-œdematous,  ulcerous,  or  m3-opathic 
forms. 

fa)  Catarrhal  Form. — In  the  catarrhal  form  the  symptoms 
are  a  sensation  of  dryness,  burning,  and  of  titillation  in  the 
throat,  which  provokes  onsets  of  dry  cough,  or  simple  hem- 
ming. In  graver  forms  respiration  becomes  slightly  painful, 
more  in  consequence  of  nasal  turgescence  than  of  laryngeal 
lesions.  The  expectoration,  nil  at  the  beginning,  becomes 
later    mucoid,    or    muco-purulent.     The    voice    is    dull    and 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     193 


broken.  Laryngoscopic  examination  usually  shows  redness, 
extending  over  the  whole  larynx.  The  epiglottis  is  of  a  rosy 
colour  ;  the  aryepiglottic  folds,  the  ventricular  bands,  and  the 
interarytenoid  region  are  sometimes  slightly  swollen.  The 
cords,  covered  with  viscid  secretions,  are  rosy,  or  even  red, 
and  er34hematous.  More  frequently  they  are  merely  rough, 
owing  to  submucous  suffusion.  In  some  cases  the  vocal 
cords  are  intensely  red,  with  diffuse  epithelial  desquamation, 
showing  small  bleeding-points. 

Paretic   lesions   are    similar   to    those    observed    in   acute 
catarrhal  laryngitis. 

(b)  Infiltro-œdematous  Form.  —  This  may  present  two 
different  varieties,  the  one  being 
characterized  by  a  sensation  of 
burning  in  the  pharyngeal  cavity, 
but  specially  by  a  true  painful 
dysphagia.  On  deglutition  the 
patient  feels  stinging  pains  in  the 
throat,  with  a  true  sensation  of 
suffocation,  the  pain  being  more 
pronounced  towards  evening  and 
during  the  night.  Phonation  is 
equally  painful,  and  the  larynx  is 
sometimes  very  sensitive  to  the 
touch.  Laryngoscopic  examina- 
tion shows  a  characteristic  very 
pronounced  œdematous  infiltration 

of  the  posterior  region  of  the  larynx.  The  mucous 
membrane,  which  covers  the  arytenoids,  is  not  only  red 
but  infiltrated,  and  projects  at  the  orifice  of  the  œso- 
phagus.  This  lesion  resembles  a  bacillary  laryngitis  at  the 
period  of  infiltration.  The  cords  are  red  and  rough,  as  in 
the  preceding  form.  In  other  cases  serous  infiltration  of 
the  aryepiglottic  folds  is  observed,  with  slight  swelling  pos- 
teriorly. Those  manifestations  are  much  less  painful  than 
in  the  above  variety  (Fig.  98).  In  tuberculous  people,  or  in 
those  affected  with  former  lesions  in  the  larynx,  influenza 
may    cause    those    rapid    infiltrations    which    give    rise    to 

13 


Fig.  98. — Influenzal  Laryn- 
gitis (Infiltro-œdema- 
Tous  Form).  (Drawn 
FROM  Nature.) 

The  arytenoid  region  is  red, 
and  infiltrated  posteriorly 
towards  the  entrance  of 
the  œsophagus. 


194  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

suffocation,   and  necessitate  immediate  opening  of  the    air 
passages. 

(c)  Ulcerative  Form. — Everyone  now  admits  that  ulcera- 
tion of  the  laryngo-mucous  membrane  may  be  caused 
by  influenza,  and  occurs  specially  in  those  patients  whose 
power  of  resistance  is  small,  such  as  in  tuberculous,  syphilitic, 
and  herpetic  subjects. 

In  mild  forms  examination  with  the  mirror  shows  small 
erosions,  covered  with  a  greyish-white  exudation,  bounded  by 
a  reddish  margin,  standing  out  on  the  vocal  cord,  which  is 
more  or  less  rough  and  rosy.  When  those  lesions  are 
superficial,  they  can  only  be  seen  by  a  strong  light.  If, 
later  on,  the  primary  desquamation  is  replaced  by  true 
ulceration,  the  edges  of  these  ulcers  are  sharply  defined, 
and  formed  by  an  inflamed  mucosa  slightly  red,  and  pro- 
jecting with  a  flattened  surface,  the  centre  of  which  is 
excavated.  The  ulcer  is  covered  with  a  greyish  pultaceous 
and  slightly  adherent  coating.  Those  alterations  are  usually 
on  the  edges  of  the  vocal  cords,  either  anteriorly  or  on  the 
posterior  third.  The  author  has  seen  them  occupying  the 
whole  cord,  but  he  has  never  met  them  on  the  ventricular 
-bands,  nor  in  the  arytenoid  region. 

Usually  those  losses  of  substance  are  symmetrical,  but 
appear  on  each  side  at  a  different  stage.  Vocal  disturbances 
are  never  absent,  and  are  generally  very  pronounced. 

(d)  Myopathic  Form.  —  Absence  of  parallelism  and  of 
tension  of  the  vocal  cords,  caused  by  irregular  contractions 
of  the  muscular  fibres  affected  with  inflammation  of  the 
subjacent  mucous  membrane,  cannot  be  described  as  paralysis. 
Those  cases  are  comparatively  rare  in  influenza,  and  are 
tractable  to  ordinary  remedial  measures. 

Spasms  of  the  glottis  are  observed  in  the  bulbar  form 
of  the  disease.  More  or  less  abrupt  interruptions  of  the 
respiratory  functions  are  occasionally  observed.  Frequently 
nervous  spasmodic  coughing  occurs,  the  cause  of  which 
cannot  be  ascertained  by  auscultation  or  percussion.  This 
cough  cannot  be  stopped  by  any  known  sedative  treatment  ; 
but  a  simple  cauterization  of  the  mucous  membrane  of  the 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     195 

inferior  or  middle  turbinais,  or  the  introduction  into  the 
nasal  fossae  of  cocainized  vaseline  (i  :  30),  may  moderate  its 
intensity. 

Diagnosis. — The  diagnosis  is  usuall}^  based  on  the  general 
symptoms  and  the  environment  of  the  subject,  more  than  on 
the  lesions  themselves,  which  occur  in  almost  all  diseases  of 
the  larynx. 

Prognosis  is  generally  benign,  but  erythema  may  follow 
and  cause  disturbances,  which  may  endanger  the  larynx  itself. 
Recurrences  are  very  frequent  after  apparent  cure.  Simple 
erosions  disappear  fairly  rapidly,  but  ulcerations  may  resist 
regular  treatment  for  months. 

Influenza  may  be  the  source  of  another  kind  of  disease 
(bacillosis),  which  may  be  recognized  by  the  persistency  of 
the  malady  and  the  aggravation  of  the  local  symptoms. 

Treatment.  —  Warm  and  emollient  drinks,  bromide  of 
potassium  and  aconite,  opiates  administered  internally, 
usually  abate  the  catarrhal  onset. 

Later  on,  local  treatment,  varying  according  to  the  degree 
of  irritation,  should  be  applied.  In  merely  catarrhal,  ery- 
thematous, and  even  mfiltro-œdematous  forms,  warm  inhala- 
tions and  cocainized  gargles,  with  rest,  will  be  sufficient  to 
dispel  the  local  manifestations.  Quinine  may  be  adminis- 
tered internally,  according  to  the  age  of  the  patient  and  the 
degree  of  the  infection. 

If  the  oedema  is  too  great,  it  should  be  treated  as  an 
cedematous  laryngitis.  If  the  erythema  is  protracted  beyond 
the  usual  limit,  or  if  erosions  or  ulcerations  exist,  the  spray 
should  be  used,  twice  or  thrice  daily,  for  three  or  five  minutes, 
according  to  the  following  formula  : 

\\  Hydrochloride       of 

ammes    gr.  4to8 

ni^lxxv 

gr.  60 

I  3xi 

Isiss 

5xiv 

13—2 


cocame    ... 

25to5ocen 

Solution  of  adrenalin 

(i  in  1,000) 

5  grammes 

Antipyrin    ... 
Glycerine                    ^ 
Cherry-laurel  water  J 
Sterilized  water 

••      4 

àâ  50 
..400 

igô 


DISEASES  OF  THE  PHARYNX  AND  LARYNX 


The  vocal  mucosa  should  be  brushed  once  or  twice  weekly 
with  a  solution  of  zinc  chloride  or  silver  nitrate  (i  :  lOO,  or 
I  :  50,  or  even  i  :  30).  In  some  recalcitrant  cases  a  course 
of  v/aters  (sulphurous  or  arsenical)  would  be  beneficial. 

Paralysis  should  be  treated  with  electricity,  either  extra-  or 
intralaryngeally,  and  congestive  onsets  with  ice  or  leeches. 
If  respiration  is  too  much  impeded,  scarifications,  or  even 
tracheotomy,  should  be  resorted  to. 


Herpetic  Laryngitis. 

Etiology. — This  disease  is  very  rarely  met  with.  It  is  due 
to  cold,  and  very  often  coincides  with  herpetic  angina. 

Symptoms.  —  Herpes  of  the 
larynx  is  accompanied  by  the 
other  manifestations  of  herpetic 
fever.  It  is  ushered  in  by 
shivering,  elevation  of  tempera- 
ture, general  fatigue,  malaise, 
even  vomiting  and  headache, 
with  coated  tongue.  Most  fre- 
quently the  mouth,  the  lips,  and 
the  soft  palate  are  involved,  but 
the  herpes  may  develop  on  the 
larynx  alone. 

Functional  disturbances  con- 
sist of  slight  pain  on  degluti- 
tion, which  becomes  almost 
always  intense.  Lateral  pressure  of  the  neck  is  equally 
painful.  The  patient  experiences  a  disagreeable  sensation 
at  the  level  of  the  larynx  ;  the  inspired  air  causes  a  feeling  of 
burning,  and  even  onsets  of  painful  coughing.  Respiration 
may  be  interfered  with  in  cases  of  œdematous  infiltration, 
but  is  usually  normal.  The  disturbances  of  the  voice  may 
vary  from  simple  huskiness  to  complete  aphonia. 

Examination  shows  very  often,  in  the  pharyngeal  cavity, 
especially  at  the  level  of  the  base  of  the  tongue  or  the  soft 
palate,  discrete  herpetic  vesicles.     Some  of  them,  character- 


FiG.  99. 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     197 

istic  of  the  disease,  are  filled  with  an  opalescent  liquid. 
Others  are  already  burst,  and  have  left  a  greyish  ulcerated 
spot,  surrounded  by  a  highly-congested  sore.  By  means  of 
the  laryngoscope  we  can  see  at  the  level  of  the  larynx, 
specially  on  the  laryngeal  surface  of  the  epiglottis  and  on 
the  aryepiglottic  folds  or  the  arytenoids,  discrete  opalescent 
vesicles  at  different  stages  of  evolution.  These  sometimes 
appear  on  the  first  day  of  the  affection,  and  at  other  times  on 
the  fourth,  fifth,  and  even  sixth.  Besides,  the  malady  pro- 
gresses by  successive  onsets,  showing  at  certain  points  small 
rounded  vesicles  containing  the  characteristic  opalescent 
liquid  of  herpes,  and  on  other  parts  whitish  spots  of  the 
size  of  a  millet-seed,  or  punctiform  erosions,  covered  by  a 
whitish  exudation,  surrowided  by  a  red  margin. 

In  confluent  herpetic  laryngitis  the  affected  region  may  be 
covered  with  a  pseudo-membranous  diphtheroid  exudation. 

Diagnosis  of  the  discrete  form  is  easy,  owing  to  general 
symptoms,  intense  local  disturbances,  and  the  appearance  of 
the  lesions.  Confluent  herpes  could  be  mistaken  for  laryn- 
geal diphtheria,  but  in  the  latter  the  false  membranes  are  not 
confined  to  the  epiglottis  or  to  the  aryepiglottic  folds,  but 
invade  the  interior  of  the  larynx,  even  the  trachea,  and 
cause  much  more  important  disturbances  (increasing  dysp- 
nœa,  progressive  aphonia,  cervical  adenitis,  and  even  Klebs- 
Loeffler's  bacillus). 

Pemphigus  of  the  larynx  is  recognized  by  the  presence  of 
larger  and  more  irregular  bullae,  and  by  the  coexistence  of 
similar  lesions  in  the  mouth  and  soft  palate.  The  pains  are 
less  pronounced  than  in  herpes. 

Treatment  consists  in  the  administration  of  light  purgatives, 
quinine,  the  use  of  emollient  fumigations,  borated  or  bromide 
gargles,  and  rest. 

Abscesses  of  the  Larynx 

are  formed  in  the  interior  or  the  neighbouring  parts  of 
the  larynx,  and  are  accordingly  intrinsic  or  extrinsic. 

Etiology. — Those  lesions  usually  occur  in  adults  and 
adolescents,   and  are  due  to  certain   debilitating  infectious 


198  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

diseases,  such  as  typhoid  fever,  small-pox,  scarlatina, 
measles,  influenza  (Moure),  and  rheumatism.  Among  direct 
causes  may  be  mentioned  cold  and  phlegmonous  affections, 
tonsillitis,  pharyngitis,  adenoiditis,  sinusitis,  etc.  Trau- 
matisms of  all  kinds — wounds,  fractures,  blows,  etc. — may 
also  give  rise  to  abscess. 

Symptoms. — When  the  abscess  of  the  larynx  is  a  con- 
comitant of  another  disease,  it  may  pass  unperceived,  at 
least  at  the  beginning,  and  afterwards  produce  a  series  of 
local  and  general  disturbances. 

(a)  Functional  Symptoms. — The  abscess  is  ushered  in  with 
febrile  S3'mptoms  of  varying  intensity.  Soon  afterwards  an 
intense  pain  in  the  neck  occurs  at  the  level  of  the  larynx, 
often  reaching  to  the  ears,  and  increased  by  deglutition  and 
pressure.  Coughing  is  extremely  painful.  The  sensation  of 
a  foreign  body  in  the  larynx  is_  more  accentuated  when  the 
oedema,  or  rather  the  oedema  of  the  neighbouring  parts,  is 
more  pronounced.  Dysphagia  depends  on  the  localit}^  of 
the  abscess.  It  is  very  intense  in  cases  of  pharyngo-laryn- 
geal  abscess,  but  much  less  when  the  abscess  is  in  the 
interior  of  the  larynx.  On  the  other  hand,  in  the  latter 
case  the  respiratory  disturbances  are  rapid  and  grave  enough 
to  endanger  life. 

Dyspnoea  is  consequent  on  the  infiltration  and  immo- 
bilization, partial  or  total,  of  one  or  of  both  arytenoids. 
The  nearer  the  tumefaction  is  to  the  vocal  cords,  the  more 
marked  is  the  alteration  of  the  voice.  The  vocal  timbre  is 
always  more  or  less  dull  ;  sometimes  complete  aphonia 
occurs.  Phonation  is  almost  always  painful.  Coughing  is 
sonorous  and  frequent  at  the  beginning  ;  afterwards  it 
becomes  characteristically  raucous.  The  secretions,  almost 
absent  at  first,  become  muco-purulent  or  even  purulent. 

(b)  Objective  Symptojns. — Extralaryngeal  abscess,  sympto- 
matic of  perichondritis,  or  an  abscess  seated  on  the  external 
parts  of  the  larynx,  is  shown  by  a  swelling  of  the  region, 
puffiness,  and  fluctuation.  Pharyngo-laryngeal  abscess  is 
characterized  by  the  swelling  of  the  lateral  grooves  of  the 
inferior    pharynx,    with    infiltration    of  the    ary-    or    glosso- 


DISEASES  AXD  TRAUMATISMS  OF  THE  LARYXX     199 

epiglottic  folds.  Sometimes  the  epiglottis  is  infiltrated  on 
one  side  and  immobilized  with  the  corresponding  part  of 
the  larynx.  The  affected  parts  are  of  a  bright  shining  red, 
standing  out  conspicuously  on  the  surrounding  mucosa. 

In  discrete  forms  a  3'ello\vish  rounded  tumour  is  observed 
on  the  glottic  folds.  Endo-laryngeal  abscess  very  often 
occupies  the  ventricular  bands,  and  sometimes  the  subglottic 
region,  occasionally  even  the  cricoid  and  tracheal  region, 
and  is  characterized  by  an  infiltration  of  the  affected  parts 
with  œdema  of  the  neighbouring  parts.  The  purulent 
accumulation,  usualh'  of  small  bulk,  attains  the  dimensions 
of  a  walnut  or  horse-chestnut. 

Pathological  Anatomy. — In  many  post-mortem  examina- 
tions pus  has  been  observed,  extending  more  or  less  into  the 
submucous  cellular  tissue.  If  suppuration  occurs  between 
the  perichondrium  and  the  cartilage,  the  latter  becomes 
necrosed  if  the  malady  is  not  checked. 

Course,  Duration,  and  Termination. — The  course  of  an 
abscess  varies  according  to  its  cause,  and  specially  to 
the  general  condition  of  the  patient.  Purulent  infiltration 
of  the  vocal  mucosa  develops  rapidly,  and  may  cause  death 
in  a  few  hours  by  asphyxia.  At  other  times  the  pus  tends 
to  burrow  its  way  to  the  surface,  producing  purulent  tracts 
in  the  neighbourhood. 

The  duration  of  the  disease  varies  according  to  the  size  of 
the  abscess  and  to  its  intensity.  Death  occurs  from  inhibi- 
tory syncope  or  asphyxia.  WJien  the  abscess  bursts,  pus 
ma}'  penetrate  into  the  bronchi  and  cause  septic  pneumonia, 
which  is  very  grave.  Among  other  possible  complications 
are  localized  emphysema  by  rupture  of  the  laryngeal  or 
tracheal  walls,  blind  fistulae  at  the  level  of  the  thyroid-hyoid 
membrane,  or  the  thyroid  cartilage  itself,  due  to  peri- 
chondritis. 

Prognosis  is  generally  grave,  the  patient  being  liable  to  die 
suddenl}'  of  heart  failure,  even  when  respiration  is  ensured  by 
tracheotomy. 

Diagnosis. — Abscess  of  the  larjmx  is  analogous  to  acute 
œdematous  laryngitis,  but  in  the  latter  no  true  pain  exists  on 


200  DISEASES  OF  THE  PHARYXX  AXD  LARYXX 

pressure,  nor  intense  dysphagia.  The  rapid  course  of  the 
œdema,  its  termination  by  resolution,  and  the  less  grave 
character  of  the  affection,  facilitate  the  diagnosis.  Ery^- 
sipelatous  laryngitis  closely  resembles  diffuse  abscess  of  the 
larynx,  and  is  distinguished  from  it  only  by  a  more  or  less 
mobility  of  the  lesion  and  the  general  symptoms  of  erysipelas. 

Laryngitis  stridulus  occurs  specially  in  young  subjects,  and 
is  differentiated  by  very  characteristic  symptoms. 

A  practised  eye  recognizes  the  presence  of  pus  under 
the  mucous  membrane,  which  latter  is  characteristically 
yellowish,  and  clearly  defined  from  the  more  or  less  red  neigh- 
bouring parts.  Palpation  is  useless,  and  possibly  dangerous, 
in  those  cases. 

Treatment — {a)  Extnilaryngenl  Abscess.  —  If  seen  at  an 
early  stage,  resolution  may  be  attempted  by  purgation,  local 
application  of  ice,  hot  poultices,  emollient  fumigation.  Re- 
solution is  aided  by  leeches,  applied  externally,  and  brushing 
with  tincture  of  iodine,  or  a  solution  of  zinc  chloride  (r  :  30). 

Should  this  treatment  fail  and  pus  be  formed,  recourse 
must  be  had  to  incision.  If  the  abscess  is  on  the  anterior 
portion,  it  should  be  opened  with  a  bistour_v  and  thoroughly 
drained  ;  if  on  the  posterior,  scarifications  should  be  made, 
or  preferably  the  abscess  opened  by  the  galvano-cautery,  or 
by  a  clean  incision.  It  is  important  to  make  an  aperture 
sufficiently  free  to  permit  the  pus  to  escape.  Generally  this 
operation  is  very  difficult,  as  the  patient  is  unable  to  open 
his  mouth  freely.  In  grave  cases  tracheotomy  must  be  per- 
formed, and  the  patient  fed  by  an  oesophageal  canula  through 
the  nose. 

(b)  Intralaryngeal  Abscess. — x\t  the  beginning  a  similar 
means  of  resolution  should  be  employed.  Later  on  the 
abscess  should  be  opened,  preferably  with  the  gal\-anic 
point,  because  this  has  the  advantage  of  making  a  large, 
deep,  and  permanent  opening,  and  avoids  hemorrhage.  The 
mucous  membrane  should  be  angesthetized  by  brushing  or 
spraying  with  a  solution  of  cocaine  (lo  or  20  per  cent.), 
mixed  with  some  drops  of  a  solution  of  adrenalm  ''i  :  1,000). 
Tracheotomy,  if  necessary,  should  be  performed. 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     201 

Chronic  Catarrhal   Laryngitis. 

A  catarrhal,  hypertrophic,  or  ulcerative  chronic  inflam- 
mation of  the  mucous  membrane  of  the  larynx. 

Etiology. — This  disease  generally  follows  acute  laryngitis. 
Chronic  suppurations  of  the  nasal  fossœ  and  naso-pharynx, 
and  especially  of  the  accessory  cavities,  predispose  to  chronic 
laryngitis  of  the  larynx. 

Heredity  seems  to  affect  this  disease. 

Singers  and  speakers,  etc.,  specially  when  they  use  their 
voice  in  an  overheated  atmosphere  or  in  an  unnatural  tone, 
or  who  are  obliged  to  speak  in  a  register  other  than  what  is 
suitable  to  the  structure  of  their  larynx,  are  particularly  liable 
to  this  lesion.  The  small  soprano  laryngés  of  women  and  the 
light  tenor  of  men  endure  fatigue  much  less  than  the  laryngés 
of  the  mezzo  and  contralto  of  women  or  the  baritone  of  men. 

Chronic  laryngitis  is  frequent  among  smokers  and  in- 
temperate subjects.  It  is  observed  in  women  during  certain 
uterine  affections,  and  particularly  during  menstruation. 

iVrthritic  and  herpetic  temperaments  may  influence  the 
development  of  the  disease. 

Although  more  usual  in  middle  age,  and  perhaps  in  men, 
chronic  laryngitis  is  met  with  in  children,  specially  between 
seven  and  ten  years  of  age,  and  notably  in  boys  after  too 
great  vocal  exertion,  or  after  eruptive  fevers. 

Symptoms. — General  symptoms  are  absent  or  slight. 

Functional  symptoms  consist  of  a  sensation  of  irritation 
in  the  pharyngeal  cavity,  or  of  a  foreign  body — as  a  pin  in 
the  posterior  wall  of  the  pharynx.  '  Hemming  "  rather  than 
coughing  is  observed,  specially  in  the  morning. 

The  most  important  symptoms  are  vocal  disturbances, 
which  are  constant.  The  voice  may  be  hoarse,  raucous,  or 
muffled.  Huskiness,  pronounced  in  the  morning,  may  dis- 
appear after  the  expulsion  of  mucus,  etc.  The  voice  may 
change  several  times  in  the  day — from  aphonia  in  the  morning 
to  almost  a  clear  intonation  in  the  afternoon.  Those  vocal 
modifications  are  more  marked  in  women  and  singers  with 
high-set  voices. 


202  DISEASES  OF  THE  PHARYXX  AXD  LARYNX 

Expectoration  is  almost  nil.  except  m  the  morning,  when 
the  patient  ejects  \\-hiti5h  or  greyish  mucus,  according  to 
the  dust  inhaled.  It  is  sometimes  gelatinous  and  even 
streaked  with  blood. 

(a)  Catarvhal  Form. — In  light  cases  the  malady  is  indicated 
by  a  simple  redness  of  the  mucous  membrane.  The  vocal 
cords  no  longer  present  a  mother-of-pearl-like  appearance, 
but  are  greyish  and  furrowed  by  a  vascular  network.  They 
are  rough,  moist,  covered  with  whitish  adherent  mucus, 
which  is  observed  to  vibrate  with  the  cords  during  the 
emission  of  the  sound  '  eh." 

In  graver  forms  the  vocal  cords  are  not  only  red,  but  very 
rough,  as  if  they  had  been  pohshed  bv  a  line  tile.  They  are 
relaxed,  owing  to  paresis  of  the  subjacent  muscle  (thyro- 
arytaenoideus).  Sometimes  they  assume  a  granular  appear- 
ance, with  small  reddish  projections.  Owing  to  the  thickening 
of  the  mucous  membrane  which  covers  the  cords,  the  latter 
appear  cylmdrical. 

The  epiglottis  is  sometimes  vascularized,  but  usually  un- 
affected. 

The  mucosa  covering  the  arytenoids  exhibits  a  velvety 
appearance.  Occasional!}-  those  svmiptoms,  though  generally 
diffuse,  are  more  pronounced  on  one  side  of  the  larynx  than 
on  the  other. 

(6)  Hypertrophic  Form. — In  h\-pertrophic  laryngitis  a  diffuse 
swelling  is  observed,  occupying  the  epiglottis,  ventricular 
bands,  and  the  cords.    All  those  parts  are  red  and  vascularized. 

The  interarytenoid  mucous  membrane  is  thickened,  pre- 
senting granular,  irregular,  and  mammillated  projections, 
which  may  be  sufticienth'  prominent  to  prevent  the  close 
approximation  of  the  arytenoid  cartilages  during  phonation. 
This  condition  may  even  extend  to  the  whole  length  of  a 
vocal  cord.  The  latter  is  perceptibly  increased  in  bulk,  and 
is  of  a  rosy  hue^  granular,  irregular,  and  lumpy  {bosselé). 
It  is  the  pathological  alteration  designated  by  ^'irchow  and 
by  the  Germans  under  the  name  of  laryngeal  pachy- 
dermia. 

There  is  nothing  characteristic  in  this,  for  it  is  seen  in  other 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     203 

conditions,  as  tuberculosis,  syphilis,  and,  according  to  some 
authors,  in  the  initial  stage  of  cancer. 

An  ulcerative  form  of  laryngitis  is  now  recognized.  Simple 
erosions  occupy  the  free  edge  of  the  vocal  cords,  the  point  of 
junction  of  the  cord,  and  the  arytenoid  at  the  level  of  the 
vocal  apophyses.  This  loss  of  substance  has  a  gouged-out 
appearance  and  prominent  red  edges. 

These  erosions,  often  single,  may  also  be  multiple. 

Fissures  or  rhagades  occur  on  the  interarytenoid  mucous 
membrane,  with  raised  edges.  They  are  painful  during  acute 
onsets,  causing  a  sensation  of  burning  and  tingling,  accom- 
panied by  a  racking  cough.  If  paresis  occurs,  it  usually  attacks 
the  thyro-arytsenoideus. 

Pathological  Anatomy. — The  dermo-papillary  transforma- 
tion of  the  vocal  mucous  membrane,  termed  by  Virchow 
laryngeal  pachydermia,  is  the  only  point  of  interest. 

Course. — Chronic  laryngitis  may  last  indefinitely,  especially 
if  the  patient  continues  in  the  profession  that  gave  rise  to  it. 
However,  hygienic  and  local  treatment  regularly  applied 
may  benefit  the  patient,  or  even  cure  the  malady.  Hyper- 
trophic forms  are  usually  more  tenacious  and  progressive, 
but  they  become  stationary  or  even  reduced  by  energetic 
treatment. 

Prognosis  is  usually  benign,  very  seldom  grave.  Yet 
pulmonary  tuberculosis  is  apt  to  develop  in  subjects  affected 
with  those  warty  conditions  of  the  vocal  cord  (inferior 
corditis). 

Diagnosis. —Some  small  polypi  of  the  vocal  cords  may  be 
confused  with  nodules,  but  the  polypus  is  generally  more 
prominent,  more  bulky,  and  single.  Superficial  erosions  or 
ulcerations  suggest  secondary  syphilis  or  tuberculosis,  but 
the  locality  of  the  lesion,  its  superficial  and  localized  appear- 
ance, and  the  absence  of  other  changes  in  the  mucous  mem- 
brane in  laryngitis  ;  oedema,  and  peripheral  infiltration  in 
tuberculosis  ;  diffuse  redness,  mucous  patches,  and  other 
changes  of  the  pharynx  in  syphihs,  complete  the  diagnosis. 

Treatment. — In  chronic  laryngitis,  of  whatever  form,  general 
treatment  should  be  adopted.    x\ny  causes  of  vocal  inflamma- 


aa  5  grammes 

fgr-  75 
igr.  75 

10 

ni^clx 

40 

5ix 

450 

3xvi 

204  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

tion  should  be  suppressed  if  possible,  and  the  patient  kept 
away  from  the  influence  of  irritating  dust  and  vapours. 
Local  remedies  consist  of  inhalations  made  with  h  litre 
of  hot  water  mixed  with  a  teaspoonful  of  the  following  : 

1^     Menthol  powdered      j  (gr-75 

Balsam  of  Peru  >     ...  âà     5  grammes      -j  gr- 75 

Balsam  of  turpentine  ;  (  gr.  75 

Tincture  of  eucalyptus     ...        300  grammes  3x 

Those  inhalations  should  be  practised  twice  or  thrice  daily 

for  five  or  six  minutes  at  a  time. 

The  following  spray  may  also  be  prescribed  : 

^     Biborate  of  soda 

Benzoate  of  soda] 

Tincture  of  eucalyptus 

Glycerine 

Water 
To  be  used  morning  and  evening  for  twelve  minutes. 

Carbolic  solutions  (i  :  1,000  or  i  :  500)  are  very  suit- 
able as  a  spray.  The  patient  should  breathe  gently  to  avoid 
fits  of  coughing.  The  most  effective  remedy  is  cauterization 
of  the  laryngeal  mucous  membrane  with  the  application 
of  cotton -wool  soaked  in  zinc  chloride  (i  :  100  or  i  :  50, 
or  even  i  :  30).  Silver  nitrate  can  be  employed  in  a 
stronger  solution  (i  :  50,  i  :  20,  or  even  i  :  10). 

Those  cauterizations  should  be  performed  twice  weekly 
at  the  beginning,  but  only  once  weekly  as  the  affection 
subsides. 

In  true  hypertrophic  or  pachydermic  forms  the  use  of 
caustics  applied  by  the  brush  is  unsatisfactory.  Curetting 
the  laryngeal  mucous  membrane  is  indispensable,  and 
should  be  performed  preferably  with  the  cutting  forceps. 
After  the  larynx  has  been  cocainized  and  adrenalized,  the 
hypertrophied  parts  should  be  punched  out.  Ignipuncture 
with  the  galvano-cautery  may  be  .successfully  applied, 
especially  when  the  hypertrophy  is  localized  in  the  inter- 
arytenoid  mucous    membrane,   or  on  the  vocal  cords.      It 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     205 

may  be  repeated,  when  necessary,  at  intervals  of  ten  to 
twelve  days. 

The  ulcerous  form  is  treated  like  that  of  a  simple  catarrhal 
lesion.  It  is  very  tenacious,  and  may  persist  for  several 
months.     A  course  of  sulphurous  waters  is  beneficial. 

It  must  be  recollected  that  laryngitis  may  depend  on  a 
nasal  affection,  and  that  the  latter  should  be  attended  to 
first. 

Laryngitis  Sicca. 

Laryngitis  sicca,  or  atrophic  laryngitis,  is  intimately  asso- 
ciated with  atrophic  rhino-pharyngitis,  and  is  usually  the 
outcome  of  atrophic  ozaenic  catarrh,  or  of  one  of  the  different 
kinds  of  strumous  pharyngitis. 

Symptoms. — The  outstanding  symptom  is  the  sensation  of 
dryness  felt  by  the  patient.  Respiration  is  inconvenienced 
by  the  accumulation  of  crusts  in  the  larynx  and  trachea. 
Coughing  is  rare  or  slight.  The  voice  is  dull  and  in  some 
cases  almost  extinct,  because  the  inflammation  of  the  cords 
is  very  often  associated  with  paralytic  disturbances  of  the 
thyro-arytenoidei.  The  secretion  is  muco-purulent,  thick, 
greenish,  often  streaked  with  blood,  is  more  profuse  in  the 
morning,  and  is  ejected  with  a  tearing  sensation.  Dyspncea, 
sometimes  approaching  suffocation,  is  due  to  the  presence 
of  dried  crusts  in  the  larynx.  Tracheal  ozaena  is  then 
observed.  Laryngoscopic  examination  shows  thick  greenish 
or  blackish  secretions  on  the  epiglottis,  the  interarytenoid 
region,  even  the  vocal  cords,  the  ventricular  bands,  the 
trachea,  and  the  ventricles. 

They  gather  as  pellets  in  the  interarytenoid  space  during 
efforts  at  phonation,  and  are  subsequently  expelled.  The 
larynx,  being  once  freed  from  those  masses,  the  cords  appear 
red,  rough,  irregular,  and  desquamated  on  their  whole  surface. 
The  posterior  region  is  rugose,  thickened,  and  fissured. 

Diagnosis  is,  as  a  rule,  easy,  owing  to  the  presence  of  crusts 
in  the  larynx. 

Prognosis  is  generally  benign,  and  a  cure  usually  takes 
place;  but  it  should  not  be  forgotten  that  the  affection  is  of 


2o6 


DISEASES  OF  THE  PHARYNX  AND  LARYNX 


a  very  chronic  type,  and  liable  to  recur,  if  treatment  is  not 
applied  regularly  to  the  laryngeal  lesion  and  the  cor3'2a  to 
which  it  is  most  frequently  due. 

Treatment,  sprays,  washes,  etc.,  should  therefore  be 
directed  to  the  naso-pharyngeal  cavities.  Locally,  sul- 
phurous or  emollient  alkaline  sprays  according  to  the  follow- 
ing formula  are  of  assistance  : 


Benzoate  of  soda 

..       8 

grammes 

ôii 

Bromide  or  iodide  of  sodium    . 

••       4 

jj 

5i 

Glycerine 

..     40 

J  J 

oviiiss 

Tincture  of  eucalyptus 

..     10 

5) 

lll^clx 

Water 

■•  450 

!5 

5  XVI 

This  should  be  used  once  or  twice  daily  for  five  minutes  at 
a  time.     Inhalations  and  the  painting  of  the  vocal  mucous 


Fig.  100. — Syringe  for  Intrai.aryngeal  or  Tracheal  Injections. 

membrane  with  iodine  solutions,  zinc  chloride,  or  silver 
nitrate  (i  :  30  or  i  :  50)  are  also  advisable.  Laryngeal 
or  laryngo-tracheal  injections  made  with  mentholated  oil 
(3  or  5  per  cent.),  with  or  without  guaiacum  or  iodoform, 
have  the  great  advantage  of  exciting  the  secretion  of  the 
mucous  membrane,  and  thus  facilitate  the  expulsion  of  crusts, 
that  encumber  the  respiratory  tracts.  Those  injections, 
according  to  the  following  formula,  may  be  repeated  either 
daily  or  once  or  twice  weekly  : 

IjL     Thymol 
Eucalyptol 
Menthol 
Liquid  vaseline 


10  centigrammes 

gr.  li 

25 

gr-4 

5  grammes 

gr.  75 

50 

5V 

DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     207 

In  obstinate  cases  benzoate  of  soda  or  sulphurous  waters 
are  strongly  recommended  for  internal  use.  The  use  of 
atomized  fluids  is  very  serviceable,  as  they  can  thus  penetrate 
down  to  the  larynx,  and  even  to  the  trachea. 

Lastly,  the  author  would  insist  on  the  recognition  and 
treatment  of  the  nasal  lesion  ;  otherwise  recurrence  may  take 
place. 

Syphilitic  Laryngitis. 

Etiology. — Prim.ary  syphilis  or  chancre  is  very  rare  in  the 
larynx,  because  this  organ  is  protected  against  the  usual 
sources  of  contamination  through  its  situation. 

Secondary  lesions,  comprising  erythema,  mucous  patches, 
condyloma,  and  paralysis,  are  due,  apart  from  syphilis  itself, 
to  the  influence  of  cold,  excessive  use  of  voice,  and,  above  all, 
to  immoderate  smoking. 

Syphilis  of  the  larynx  in  primary  or  secondary  form  is 
observed  between  the  ages  of  twenty  and  forty.  Tertiary 
forms  are  more  frequent  beyond  that  age. 

Symptoms. 

(a)  Chancre. — The  most  outstanding  is  the  existence  of 
pain  on  deglutition,  due  to  a  greyish  rough  ulceration,  sur- 
rounded by  a  red  inflammatory  zone.  Generally  a  series  of 
indurated  lymphatic  glands,  loose  and  painless,  is  observed 
in  the  submaxillary  region.  Those  various  symptoms  are 
not  characteristic,  and  diagnosis  should  be  based  specially 
on  the  age  of  the  patient,  the  abruptness  of  the  onset,  and 
the  manifestations  of  the  secondary  stage. 

(b)  Secondary  Lesions — i.  Erythema. — In  the  first 
stage  erythema  occurs  very  frequently,  and  is  characterized 
by  a  dark  redness,  diffuse  or  localized — specially  at  the  level 
of  the  vocal  cords — towards  their  anterior  insertion  on  their 
free  edges,  or  on  the  ventricular  bands.  This  redness  is 
formed  by  the  close  collection  of  minute  red  punctate  spots. 
The  eruption  is  accompanied  by  analogous  lesions  on  the 
skin  and  on  the  pharyngeal  cavity,  and  may  persist  even 
when  the  mucous  patches  appear.     Some  small  erosions,  due 


2o8  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

to  a  desquamation  of  epithelium,  are  sometimes  observed  in 
erythema.  Secretion  is  increased,  becomes  viscid,  and  dries 
up  at  the  level  of  the  vocal  cords  in  subjects  with  chronic 
coryza,  and  especially  with  atrophic  coryza. 

2.  The  existence  of  mucous  patches,  which  has  long 
been  disputed,  is  now  admitted.  They  appear  usually  con- 
currently with  roseola  of  the  skin,  and  coincide  almost  always 
with  buccal  or  anal  patches.  Their  usual  seat  is  at  the  level 
of  the  epiglottis,  or  on  the  glosso-epiglottic  folds,  the  ven- 
tricular bands,  and  the  vocal  cords.  They  are  most  frequently 
isolated,  projecting,  greyish,  with  a  rough,  goffered  surface, 
and  surrounded  by  an  inflammatory  zone,  standing  out  on 
a  red  or  even  swollen  mucous  membrane.  On  the  vocal 
cords  the  mucous  patch  is  greyish,  somewhat  projecting,  of 
an  almost  diphtheroid  appearance,  but  surrounded  by  a 
clearly  defined  edge  of  a  carmine  red.  Those  lesions  occur 
on  one  or  both  vocal  cords,  usually  on  their  superior  surface, 
more  rarely  on  their  free  edge. 

3.  Œdema. — Around  the  mucous  patches  the  mucosa 
becomes  swollen  and  œdematous,  so  as  to  produce  glottic 
constriction,  with  onsets  of  suffocation.  Secondary  inflam- 
matory tumefaction  occupies  almost  always  the  epiglottis 
and  its  folds,  more  rarely  the  ventricular  bands  and  the  sub- 
glottic region.  Those  grave  complications  are  met  with  in 
syphilitic  patients  who  use  their  voice  in  excess,  or  immoder- 
ately indulge  in  tobacco  and  alcohol.  The  buccal  patches 
in  those  patients  become  ulcerated  and  phagedenic.  Violent 
and  inopportune  cauterization  may  also  give  rise  to  this 
condition. 

4.  Condyloma  is  much  rarer  in  the  secondary  stage, 
but  the  author  has  seen  it  in  a  little  girl  of  six,  where  the 
anterior  pillars  and  the  lingual  base  of  the  epiglottis  were 
covered  with  those  papillary  tumours  of  a  greyish  white 
colour,  with  here  and  there  rosy  spots.  Similar  secondary 
condylomata  have  been  observed  on  the  ventricular  bands, 
and  even  in  the  posterior  region. 

5.  Paralysis  is  usually  unilateral,  and  seems  to  be  more 
frequently  met  with  on  the  left  side.     The  paralyzed  cord 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     209 


is  almost   always  immobilized  in  its  medial  position,  as  in 
recurrent  paralysis. 

6.  Functional  Disturbances. — During  the  erythematous 
stage  the  timbre  of  the  voice  is  hardly  affected,  but  may 
sometimes  become  raucous.  When  the  mucous  patches 
appear,  the  vocal  disturbances  become  more  pronounced,  and 
according  to  the  seat  and  intensity  of  the  lesion,  broken 
voice,  or  even  aphonia,  occur.  If  the  patches  are  all  extra- 
laryngeal,  a  slight  pain  may  be  felt  on  deglutition. 

In  the  case  of  œdema — dysphagia,  respiratory  disturbance, 
and  even  fits  of  suffocation,  occur  over  and  above.  When 
paralysis  takes  place  the  voice  is  bitonal,  dull,  or  even  extinct, 
according  to  the  degree  of  paralysis.  If  the  vocal  cord  is  fixed 
mesially,  the  voice  may  remain  normal,  or  hardly  altered  in 
its  timbre. 

Tertiary  Accidents. — They  generally  occur  long  (ten  to 
twenty  years)  after  the  primary  affection.  Tertiary  syphilis 
may  be  hereditary.  Formerly  considered  rare,  it  is  recognized 
to  be  more  common,  since  laryngoscopy  has  been  practised. 

I.  Gumma. — Circumscribed  gummatous  tumours  have 
usually  a  smooth,  even,  reddish  surface,  and  are  clearly  defined 
by  a  peri-infiammatory  in- 
filtration. When  the  gumma 
is  about  to  become  soft,  small 
yellowish  projections  appear 
where  the  crateriform  ulcera- 
tion takes  place.  These  be- 
coming contiguous,  give  the 
mucous  membrane  an  ir- 
regular mammillary  appear- 
ance. These  lesions  rest  on 
an  infiltrated  basis. 

The  infiltrated  gumma  appears  as  a  red,  smooth,  inflam- 
matory, elongated  swelling;  the  affected  portion  is  much 
distorted,  and  frequently  disappears. 

Those  syphilitic  lesions,  in  order  of  frequency,  occur  on  the 
base  of  the  tongue,  the  epiglottis,  the  ventricular  bands,  the 
aryepiglottic  folds,  the  vocal  cords,  and  especially  in  the  sub- 

14 


Fig.  ioi.— Gummatous  Infiltra- 
tion OF  THE  Right  Ventri- 
cular Band. 


DISEASES  OF  THE  PHARYNX  AND  LARYNX 


glottic  region  ;  they  are  usually  unilateral,  and  may  pass  from 
one  side  to  the  other. 

The  affected  part  is  only  immobilized,  when  crico-arytenoid 
arthritis  simultaneously  exists.  It  is  not  rare  to  see  gum- 
matous infiltration  pass  from  one  side  to  the  other,  and 
invade  the  two  sides  of  the  organ. 

2.  Ulcerations. —  Ulcerations  usually  constitute  the 
second  stage  of  the  gummatous  process,  but  the  phase  of 

infiltration  may  develop  so 
rapidly  as  to  pass  unperceived, 
and  ulceration  is  present  by 
the  time  advice  is  sought. 
Ulceration  rapidly  gains  in 
breadth  and  depth,  penetrat- 
ing into  the  chorion  of  the 
mucous  membrane,  the  sub- 
mucous tissue,  and  reaching 
the  cartilage,  which  first 
becomes  ossified,  and  then 
necrosed.  The  larynx  is 
filled  with  red  polypoid-like 
granular  vegetations,  and  the  edges  of  the  ulcer  become 
infiltrated,  if  treatment  does  not  check  the  progress  of  the 
affection.  The  epiglottis — shredded,  ragged,  and  perforated — 
disappears  almost  entirely,  and  the  interior  of  the  larynx 
becomes  deformed  from  loss  of  substance.  The  ulceration 
assumes  an  irregularly  indented 
and  fringed  appearance  ;  its  edges 
project,  more  or  less  sharply  de- 
fined, and  are  sometimes  under- 
mined by  the  ulcerative  process. 
These  semi-detached  masses  of  the 
mucous  membrane  swaying  in  the 
interior  of  the  larynx  produce 
suffocation,  if  not  removed  by  the 
forceps.     According  as  the  ulcers 

follow  a  circumscribed  or  a  diffuse  gumma,  the  ulceration 
gains  in  depth,  and  reaches  the  perichondrium  or  cartilage. 


Fig.  102. — Tertiary  Ulceration  OF 
THE  Epiglottis,  of  the  Ventri- 
cular Band,  and  of  the  Aky- 
epiglottic  Fold  (Right  Side). 

The  left  side  of  the  epiglottis  is  very 
infiltrated,  as  well  as  the  ary- 
epiglottic  folds. 


Fig.  103. — Tertiary  Ulcera- 
tion WITH  almost  Total 
Destruction  of  the  Epi- 
glottis. 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     211 


Fig.  104. — Tertiary  Ulcera- 
tion WITH  Destruction  of 
THE  Epiglottis,  its  Folds, 
AND  THE  Arytenoid  Region, 

TOGETHER  WITH    DEFORMITY 

OF  THE  Larynx. 


or  extends  to  the  neighbouring  parts — the  pharynx  or  the 
base  of  the  tongue. 

3.  Perichondritis. — In  some  cases  the  perichondrium 
and  the  cartilages  are  attacked 
first.  The  ulceration  is  then 
secondary.  In  those  forms  the 
vocal  apparatus  is  completely 
destroyed  by  vast  necrotic  ulcera- 
tion. In  those  kinds  of  primary 
perichondritis  the  swelling  is 
visible  externally,  and  there 
exists  in  front  of  the  larynx  that 
distinctive  carapace  character- 
istic of  thyroid  perichondritis. 
The  cartilage  is  painful  to  the 

touch,  and  external  fistular  tracts  are  observed,  which  may 
penetrate  internally. 

4.  Pseudo-poiypoidal  Form. — Some  syphilitic  patients 
present  true  pseudo-poiypoidal  forms,  diffuse  degenerations 
invading  the  whole  larynx.  These  lesions  almost  resemble 
diffuse  papillomata  of  the  larynx,  but  the  bosses  are  more 
voluminous,  redder,  and  more  projecting.  The  posterior 
region  and  the  ventricular  bands  are  thickened  and  infiltrated, 
resembling  pachydermia.  The  degenerations  only  partly 
recede  under  specific  treatment,  and  the  forceps  and  galvanic 
cautery  should  always  be  applied. 

5.  Laryngeal  Stenosis. — The  above  alterations  often 
leave  permanent  scars — various  constrictions  characterized 
by  adhesion  of  the  two  vocal  cords,  or  by  the  formation  of 
a  true  membrane  which  unites  them.  In  other  cases 
one  of  the  arytenoids  becomes  ankylosed.  The  elimination 
of  some  cartilages  may  also  be  the  cause  of  laryngeal 
stenosis.  Finally,  a  true  annular  constriction  may  take 
place.  Those  various  affections  of  the  mucous  membrane 
are  easily  recognized  by  laryngoscopic  examination.  When 
a  web  exists,  a  whitish  membrane,  greyer  and  less  glitter- 
ing than  the  cords,  is  seen  during  inspiration,  generally 
occupying  the    anterior    third    of  the    larynx,    and    forming 

14—2 


212  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

a  crescent,  the  concave  edge  of  which  is  directed  back- 
wards. 

6.  Paralysis  is  observed  in  the  tertiary,  as  well  as  in  the 
secondary  period,  and  may  be  attributed  to  recurrent  com- 
pression or  myopathic  causes,  as  peripheral  neuritis.  Those 
different  forms  of  syphilis  may  occur  concurrently. 

Functional  symptoms  of  the  tertiary  period  are  not  very 
characteristic.  The  voice  may  remain  almost  normal  or 
become  extinct,  according  to  the  locality  of  the  lesion. 

Expectoration,  usually  nil,  may  in  cases  of  ulceration 
become  muco-purulent,  streaked  with  blood,  or  even  fetid 
when  perichondritis  or  necrosis  exists.  The  detritus  of 
ossified  and  necrosed  cartilages  is  found  in  the  expectora- 
tions. 

Respiration  is  sometimes  not  interfered  with,  but  the 
respiratory  disturbances  may  become  grave,  even  attaining 
to  stertorous  breathing  and  asphyxia.  Those  troubles  are 
usually  more  pronounced  during  the  night,  and  are  the  more 
pronounced  the  more  rapid  the  affection.  In  gradually 
developing  stenosis  the  patient  gets  accustomed  to  the 
impeded  breathing,  and  the  glottic  orifice  may  be  very 
narrow,  although  little  pain  is  felt. 

Stridor,  when  it  exists,  takes  place  both  during  inspiration 
and  expiration,  but  is  more  pronounced  in  the  former. 
Asphyxia  may  be  rapid,  even  abrupt,  if  a  fragment  of  carti- 
lage or  of  sphacelated  mucous  membrane  falls  into  the  air 
passages,  or  if  acute  cedematous  infiltration  has  taken  place. 

Fetor  of  the  breath  is  rare.  If  it  is  present,  the  nasal 
fossae  and  the  lungs  should  be  explored  to  discover  the 
necrotic  or  gangrenous  focus. 

Spontaneous  pains  are  usually  absent.  Pressure  at  the 
level  of  the  larynx  is  almost  painless,  unless  the  cartilages  are 
affected  with  perichondritis.  Deglutition  is  generally  un- 
accompanied by  pain,  unless  the  inflammation  occupies  the 
epiglottis  or  the  posterior  region  of  the  larynx,  in  which  case 
the  pain  may  become  very  acute,  and  prevent  the  patient 
from  taking  food.  Liquids  produce  a  sensation  of  burning, 
extending  up  to  the  ears.     Often,  even   liquids  regurgitate 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     213 

through  the  nose,  or  penetrate  into  the  air  passages,  causing 
violent  spasms  of  coughing.  The  sensibihty  of  the  pharyn- 
geal cavity  is  somewhat  dulled.  In  those  cases  laryngo- 
scopic  examination  is  easy,  whereas  in  tuberculosis  it  is  very 
difficult. 

Course,  Duration,  and  Termination. — The  course  of  laryn- 
geal syphilis  is  usually  prolonged.  Erythema  and  mucous 
patches  may  last  for  several  months,  also  the  vox  syphilitica 
which  accompanies  it.  However,  the  complications  of  the 
secondary  period  gradually  yield  to  a  well-directed  treat- 
ment. Paralysis  alone  is  permanent.  The  voice  may  re- 
cover its  normal  timbre,  although  one  of  the  cords  remains 
paralyzed,  owing  to  the  compensation  of  the  other. 

The  duration  of  these  tertiary  lesions  depends  on  their 
form,  intensity,  and  age.  If  the  patient  has  taken  timely 
advice,  the  cure  rapidly  follows.  If,  on  the  other  hand, 
the  cartilages  and  the  perichondrium  are  affected,  no  result 
can  be  obtained  for  months.  Finally,  if  arthritis,  and  spe- 
cially infiltration  with  perichondritis,  exist,  the  disease  is 
very  obstinate,  and  recurrence  is  common,  particularly  in 
smokers,  who  will  not  give  up  that  habit. 

The  termination  of  the  secondary  stage  is  complete  resolu- 
tion, without  scarring.     The  lesions  are  merely  superficial. 

Tertiary  syphilis  leaves  no  trace  if  treatment  has  been 
applied  sufficiently  early  and  energetically.  On  the  con- 
trary, in  grave  forms,  where  the  tissues  and  the  cartilages  are 
much  damaged,  the  malady  ends  with  synechiae  and  scars. 

Diagnosis. — During  the  secondary  period  syphilitic  erythema 
and  mucous  patches  are  easily  recognized  by  the  coexistence 
on  the  throat,  etc.,  of  similar  lesions.  Syphilitic  glandular 
involvement  and  corresponding  lesions  of  the  scalp  facilitate 
diagnosis.  Infiltration  alone  might  produce  a  confusion 
between  syphilis  and  tuberculosis,  but  tumefaction  is  more 
rapid  in  syphilis  than  in  tuberculosis.  Moreover,  secondary 
syphilitic  infiltrations  rarely  exist  without  the  neighbouring 
parts,  soft  palate,  pillars,  and  tonsils,  being  also  similarly 
attacked. 


214  DISEASES  OF  THE  PHARYXX  AXD  LARYXX 

At  the  ulcerative  stage  the  tertiary  lesions  may  be  con- 
fused with  those  of  tuberculosis,  but  functional  disturbances, 
especially  coughing,  dysphagia,  and  expectoration,  are  more 
pronounced  in  tuberculosis  than  in  syphilis.  Discoloration 
of  the  tissues  and  diffusion  of  the  lesions  belong  rather  to  the 
former,  which  is  found  most  generally  on  the  posterior  por- 
tion of  the  larynx.  Finally,  the  general  state  of  the  patient, 
the  examination  of  the  expectoration,  or  of  a  small  portion 
of  the  lesion,  will  clear  up  the  diagnosis. 

Cancer  may  also  be  confused  with  a  gumma  at  the  outset 
of  its  ulcerative  stage.  In  both  cases  a  deep  red  circum- 
scribed swelling,  occupying  either  one  of  the  ventricular 
bands  or  the  epiglottis,  is  observed.  In  both  cases  the 
affected  part  is  painless,  but  the  course  of  the  two  affections 
is  very  different.  Spontaneous  pain,  with  radiation  towards 
the  nape  of  the  neck  or  the  bottom  of  the  throat,  ma}'  be 
considered  characteristic  of  cancerous  lesions.  Small  haemor- 
rhages, or  at  least  the  presence  of  blood  in  the  expectorations, 
point  to  neoplastic  ulceration  rather  than  to  simple  gumma. 
The  breath  is  more  fetid  in  malignant  ulcerated  tumours. 
The  course  of  the  disease  is  much  more  rapid  in  syphilis. 

At  the  stage  of  tumefaction  diagnosis  is  usualh-  much 
easier,  because  the  warty  appearance  of  the  cancer  could  not 
be  confused  with  a  fungous  syphilitic  ulceration,  where  the 
globular  projection  is  less,  and  the  ulcerated  part  more  diffuse 
and  serpiginous.  The  cancerous  tumour  is  liable  to  bleed, 
and  is  surrounded  bv  an  inflammator}-zone,  hard,  wood}',  and 
infiltrated,  which  is  not  found  to  such  an  extent  in  syphilis. 

In  malignant  neoplasms  the  affected  vocal  cord  is  usually 
immobilized  very  early,  a  fact  which  occurs  almost  ex- 
clusively in  syphilitic  arthritis. 

The  presence  of  perichondritis  with  a  laryngeal  carapace 
is  usuallv  symptomatic  of  cancer.  If  it  is  seen  in  syphilis,  it 
occurs  at  a  stage  at  which  the  disease  cannot  be  mistaken. 
In  hybrid  cases  diagnosis  is  very  difficult,  but  in  those  forms 
the  lesions  usually  invade  the  base  of  the  tongue,  often 
even  the  pharynx,  causing  serpiginous  ulcerations  with  pro- 
jecting edges   (syphilis),  or  red   indurated   infiltrated  folds, 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     215 

with  warty  tumours,  bleeding  easily,  adherent,  and  accom- 
panied by  hard  and  painful  adenopathy  (cancer). 

Lupus  possesses  sufficiently  well-defined  characteristics  to 
prevent  its  being  mistaken  for  syphilitic  ulcerations.  More- 
over, the  ulcer  is  distinguished  by  fungous  rosy  projections, 
rather  than  by  true  ulcerous  loss  of  substance. 

Apart  from  cutaneous  symptoms,  leprosy  presents  clearly 
marked  symptoms,  which  will  be  afterwards  dealt  with. 
Histological  examination  will  clear  up  the  diagnosis. 

Prognosis. — Syphilis  in  the  larynx  is  graver  than  in  other 
organs.  Erythema  is  dangerous  or  serious  only  for  pro- 
fessionals, but  oedema  of  the  larynx  is  always  grave,  and 
paralysis  at  this  stage  may  necessitate  surgical  intervention. 

At  the  tertiary  period  the  complications  are  much  more 
dangerous,  for  often  the  patient  seeks  medical  advice  when 
the  lesions  are  too  far  advanced. 

Stenosis,  consequent  on  destructive  ulceration,  is  one  of  the 
most  dangerous  features  in  the  prognosis.  Tracheotomy  may 
prevent  death,  but  frequently  the  patient  is  obliged  to  retain 
the  canula  permanently.     Fatal  haemorrhages  also  occur. 

Treatment. — Some  authors  favour  an  exclusively  mercurial 
treatment,  others  believe  in  iodine.  The  author,  when  he 
has  to  act  promptly  and  energetically  in  syphilis  of  the 
larynx  and  pharynx,  prescribes  a  mixed  treatment.  If  it  is  a 
case  of  constitutional  syphilis,  mercury  should  be  prescribed  at 
the  secondary  stage,  and  mixed  treatment  during  the  tertiary. 

When  the  mixed  treatment  is  adopted,  mercury  may  be 
used  in  the  form  of  pills,  ointment,  or  subcutaneous  m- 
jections,  whereas  iodide  of  potassium  or  of  sodium  is 
administered  internall}^  Contrary  to  some  practitioners, 
the  author  does  not  recommend  large  doses  ;  even  in  ex- 
ceedingly grave  cases  he  never  exceeds  3  grammes  of  iodide 
a  day,  administered  according  to  the  following  formula  : 

R  Biniodide    of   mer- 
cury solution  15  to  20  centigrammes      gr.  2|  to  3 
Iodide  of  potassium       15  to  25  grammes  3iiissto5vi 
Aqua      ...              ...     300            ,,  3x 

Two  tablespoonfuls  a  day  before  food  in  a  little  sugared  water. 


2i6  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

Usually  the  iodide  causes  inflammatory,  even  œdematous, 
onsets,  which  might  suggest  a  wrong  diagnosis,  but  those 
onsets  disappear  after  five  or  six  days.  If  the  glottic  stenosis 
is  too  pronounced,  the  practitioner  should  be  read}^  to  open 
the  air  tract. 

Local  Treatment. — First  suppress  every  cause  of  irritation, 
as  alcohol  and  tobacco.  Painting  with  biniodide  solution, 
or  with  one  of  silver  nitrate  (i  :  50  or  i  :  30),  should  be 
practised.  Cauterization  in  the  larynx  with  acid  nitrate 
of  mercury  (i  :  50  or  i  :  30)  is  more  active,  but  is  liable 
to  cause  glottic  spasm. 

During  the  tertiary  period  local  cauterization  in  the 
larynx  should  only  be  performed,  if  the  patient  is  not  too 
intolerant.  The  best  remedies  at  this  stage  are  dilute  solu- 
tions, or  even  pure  tincture  of  iodine  or  chromic  acid,  when 
the  ulcerations  are  seated  outside  the  larynx.  If  débris  of 
mucous  membrane  or  of  cartilages,  or  too  voluminous 
warty  swellings  exist,  they  should  be  removed  by  suitable 
forceps. 

Post-ulcerous  scars  and  membranous  bridges  may  be  excised 
with  a  laryngeal  knife,  or  by  the  galvano-cautery  after  the 
application  of  cocaine  and  adrenalm.  A  mere  section  is 
not  always  sufficient,  and  must  be  supplemented  by  a  slow 
and  progressive  dilatation  of  the  laryngeal  orifice. 

Laryngo-stenosis. 

Etiology. — Laryngo-stenosis  supervenes  after  an  ulcerative 
affection  of  the  larynx,  but  is  sometimes  congenital. 

Acute  subnjucous  and  perichondritic  diseases  (scarlatina, 
measles,  small-pox,  and  typhoid  fever)  frequently  terminate 
in  cicatricial  stenosis,  which  results  from  cicatricial  ad- 
hesions, or  from  necrosis  of  the  cartilages. 

Lupus  and  subacute  tuberculosis,  when  they  recede,  may 
cause  laryngo-stenosis,  from  the  cicatrization  of  diffuse 
ulcerations,  or  from  the  slow  formation  of  a  fibrous 
cicatricial  tissue. 

Syphilis  at  the  tertiary  period,  scleroma,  violent  burns, 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYXX     217 

fractures,  even  external  laryngeal  operations,  intubation,  and 
tracheotomy,  may  also  produce  constriction  of  the  larynx. 

In  point  of  fact,  the  presence  of  the  tube  directly  under 
the  vocal  cords  causes  continual  irritation  and  subglottic 
infiltration,  thus  preventing  its  subsequent  withdrawal. 
Moreover,  the  section  of  the  cricoid  in  young  subjects  occa- 
sions the  forcible  opening  of  the  cricoid  ring,  and  conse- 
quently immobilizes  the  two  arytenoids  in  the  middle  line. 
Abduction  of  the  vocal  cords  is  consequently  impeded  during 
the  act  of  inspiration.  Should  the  canula  remain  in  situ  for 
a  short  time  only,  the  crico-arytenoid  articulations  have  not 
got  time  to  become  fixed  in  this  position  ;  but  if  the  canula 
is  not  removed  for  several  weeks,  or  â  fortiori  for  several 


Fig.  105. — Appearance  of  the  Stenosed  Larynx  during 
Inspiration. 

The  arytenoids  do  not  separate  from  the  middle  line,  and  the  subglottic 
region  is  infiltrated. 


months,  stiffness  of  articulation  ensues,  which  does  not  dis- 
appear on  the  removal  of  the  canula.  x\ccording  to  the 
author's  opinion,  this  constitutes  the  laryngeal  stenosis,  which 
is  erroneously  attributed  to  laryngeal  spasm.  Apart  from 
mechanical  deformity,  inflammatory  stenosis  may  also  result, 
and  this  may  only  be  prevented  by  the  removal  of  the  canula, 
or  by  inserting  it  in  another  part  of  the  larynx  (inferior 
tracheotomy). 

Those  inflammatory  laryngo-stenoses  in  young  people  are 
almost  always  the  result  of  intercrico-thyroid  tracheotomy, 
in  which  the  cricoid  had  been  severed.  The  author  does 
not  refer  to  cases  where  section  of  the  air  passage  has  been 
made  on  the  thyroid,  almost  in  the  middle  of  the  vocal  cords. 


2i8  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

In  these  cases  inflammation,  following  the  use  of  the  canula, 
is  sufficient  to  account  for  the  stenosis. 

Other  causes  of  laryngo-stenosis  are  external  laryngeal 
operations — e.g.,  removal  of  half  the  thyroid,  and  partial  resec- 
tion, more  or  less  considerable,  of  the  laryngeal  framework. 

Symptoms — Diagnosis. — The  symptoms  vary  according  to 


Fig.  io6. — Antero-posterior  Section  showing  the  Tracheal  Canula  in 

THE    CRICO-THYROID    SpACE,    AND     INDICATING     ITS    CLOSE    CONNECTION 

WITH  THE  Subglottic  Region. 

I,  Border  of  the  ventricular  band  ;  2,  ventricle  ;  3,  vocal  cord  ;  4,  orifice  of 
the  canula  ;  5,  section  of  the  arytenoid  ;  6,  section  of  the  cricoid  ; 
7,  section  of  the  thyroid  cartilage. 


the  nature  and  cause  of  the  constriction.  The  main  dis- 
turbances are  those  of  the  voice,  which  becomes  dull  or  even 
extinct,  and  of  respiration.  The  latter  may  not  be  inter- 
fered with,  although  the  stenosis  is  very  pronounced,  if  it 
has  taken  place  slowly. 

It   is  of  importance  to    distinguish  superficial  cicatricial 
stenosis  from  stenosis  en  masse,  in  which  the  whole  laryngo- 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     219 

tracheal  passage  is  thickened,  narrowed,  and  transformed 
into  a  kind  of  fibrous  tube,  with  an  irregular  opening  more 
or  less  rigjid. 


Fig.  107. — Fibrous  Band  uniting  the  Vocal  Cords,  and  only  leaving 
AN  Opening  Pervious  Posteriorly  (Arytenoid  Region). 

Prognosis  depends  on  the  form,  nature,  and  duration  of 
the  constriction. 

Treatment. — If  the  constriction  is  due  to  a  simple  mem- 
branous bridge,  or  to  a  fibrous  band  extending  from    one 


Fig.  ic 


-Whistler's  Olive-headed  Bougie  for  Cutting  Membranous 
Bridges. 

A,  Olive-shaped  extremity  concealing  the  blade  C,  which  appears 
in  B  when  the  spring  is  pressed. 


vocal  cord  to  the  other,  or  over  the  vestibule  of  the  larynx,  a 
simple  incision  with  the  galvano-cautery,  followed  by  dilata- 
tion, will  keep  the  passage  patent. 

In  inflammator}^  forms  irritating  agents  should  first  of  all 
be  suppressed,  and  then  an  appropriate  treatment  applied. 
If  the  stenosis  results  from  the  canula  being  placed  in  the 
intercrico-thyroid  space,  with  section  of  the  cricoid,  it  will 


220  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

be  sometimes  possible  to  keep  the  tract  open  by  inserting 
the  canula  below  the  second  or  first  ring.  In  true  chronic  and 
tubular  forms  the  best  treatment  is  dilatation,  either  before 
or  after  tracheotomy.  Schrotter's  tubes  (hollow-stemmed 
and  following  the  curve  of  the  larynx)  are  the  simplest  to 
employ.     These   tubes  vary  in  thickness  from  g  to  21  milli- 


FiG.  109. — Schrotter's  Laryngeal  Dilator  in  Metal  (Nos.   i  to  12). 

metres  antero-posteriorly,  and  from  8  to  14  millimetres 
transversely,  and  are  made  of  vulcanite,  nickel,  etc.,  so  as 
to  be  aseptically  cleaned.  The  tube,  slightly  warmed  and 
coated  with  vaseline,  should  be  introduced  with  the  finger, 
or  preferably,  in  the  case  of  adults,  under  the  control  of  the 
laryngeal  mirror.  The  characteristic  noise  of  the  tubular 
breathing,    onsets   of  coughing,  and   the  ejections  of  some 


Fig.  1 10. — Schrotter's  Laryngeal  Dilator  in  Vulcanite 
(Nos.  I  TO  12). 

mucus,  indicate  that  the  tube  has  passed  the  constricted 
part.  It  is  sometimes  necessary  to  cocainize  the  glottic 
mucous  membrane,  and  even  to  adrenaline  it. 

At  the  outset  the  tubes  can  hardly  be  tolerated  for  more 
than  a  few  minutes,  but  gradually  the  patients  become 
accustomed  to  bear  them  for  several  hours.     The  frequency 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX    221 

with  which  dilatation  should  be  practised  varies  according 
to  the  irritation  produced  by  it,  the  patient  being  kept  under 
supervision,  because  tracheotomy  may  become  necessary  at 
any  time. 

Schrotter  tubes  are  now  superseded  by  those  of  O'Dwyer. 
The  latter  are  an  excellent  means  of  treating,  with  or  without 
tracheotom}',  chronic  atresia  of  the  larynx.  In  such  cases 
a  tube  with  a  large  head  and  a  small  body  should  be  pre- 
ferred, as  it  is  more  easily  tolerated  by  the  patient.  The 
shape  of  the  tube  must  be  adapted  to  the  degree  and  form 


Fig.   III. — Navratil's  Dilator. 

Olive-shaped  extremity  closed  ;  d',  the  same  open  ;  /;,  handle  of  the 
instrument  ;  sc,  handle  enabling  the  part  m,  which  is  furnished  with  a 
scale,  to  indicate  the  degree  of  dilatation  of  the  blades  of  the  olive-shaped 
extremit}'. 


of  the  constriction.  Too  small  tubes  are  to  be  avoided, 
as  they  are  liable  to  be  expelled  spontaneously,  or  fall  into 
the  trachea.  Massei  and  Lefferts  recommend  vulcanized 
tubes  as  being  less  irritating.  Dilatation  must  be  supervised 
carefully,  lest  inflammation  take  place. 

Most  frequently  dilatation  is  made  after  tracheotomy  in 
order  to  avoid  asphyxia,  and  is  performed  by  forcible  dila- 
tation with  Fauvel's  forceps.  This  treatment  has  not  given 
good  results  in  true  cicatricial  stenosis.  Egidi  advises  the 
combination  of  resection  of  the  cicatricial  tissue  around  the 


222  DISEASES  OF  THIS  PHARYNX  AND  LARYNX 

canula,  and  five  or  six  days  afterwards  forcible  dilatation  with 
a  dilator  introduced  through  the  tracheal  orifice  ;  but  this 
procedure  is  suitable  only  in  a  few  forms  of  laryngo-stenosis. 
Schrotter's  tubes,  Beniquet's  tin  bougies,  metallic  drills,  and 


Fig.  112. — Dr.  Boulay's  Canula  and  Dilator. 

Boulay's  catheter  should  be  used  in  turn,  according  to  the 
necessity.  Boulay's  instruments  are  designed  specially  for 
children.  This  author  recommends,  that  for  an  ordinary 
tracheal  canula  there  should  be  substituted  one  with  double 


Fig.  113. — Schrotter's  'Olives'  introduced  by  the  Mouth. 

special  window.  The  child  being  placed  by  an  assistant  in 
the  laryngoscopic  position,  a  catheter  of  medium  calibre  may 
be  introduced,  either  directly  by  causing  him  to  retch,  thus 
raising  the  epiglottis  and  enabling  the  operator  suddenly  to 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX 


223 


introduce  the  tube,  or  by  the  aid  of  the  mirror.  The  catheter 
is  left  for  a  few  moments,  then  taken  out,  and  replaced  by 
a  somewhat  larger  one,  and  so  on.  In  the  interval  the 
ordinary  canula  is  used.     When  the  dilatation  is  sufficient 


Fig.   114. — Dilating  Canula  acting  from  Below  Upwards. 

to  admit  a  tube  of  medium  size,  intubation  should  be  pre- 
ferred to  calibration.  The  most  important  point  is  to  avoid 
making  a  false  passage  through  the  tissues,  and  therefore  the 
procedure  should  be  carried  out  gently. 

If  the  above  means  fail,  protracted  dilatation  should  be 


Fig.   115. — Dr.  Sevestre's  Series  of  Tubes. 

made  with  Schrotter's  '  olives.'  The  latter  consist  of  a  series 
of  small  dilators  of  olive  form,  the  inferior  part  of  which  has 
a  rounded  knob,  whereas  the  superior  portion  is  furnished 
with  a  tiny  flattened  perforated  stem,  vv^ith  a  small  hole  to 


224  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

allow  the  passage  of  a  thread.  The  olive  being  thus  sus- 
pended is  inserted  into  a  hollow  stem,  following  the  laryngeal, 
curve,  and  is  supported  by  a  handle,  which  serves  to  intro- 
duce it.  Once  the  latter  is  in  position,  the  thread  is  released, 
and  the  olive-holder  is  then  withdrawn  alone.  The  inferior 
knob  of  the  bougie  is  fixed  by  means  of  special  thin  forceps 
introduced  into  the  tracheal  canula. 

Generally  these  tubes  cause  pain  or  inflammation,  which 
do  not  permit  continuation  of  the  treatment. 

Some  authors  have  recommended  the  use  of  rubber  bougies. 
Thost  of  Hamburg  advises  a  series  of  conical  bougies  intro- 
duced from  below  upwards.  Indiarubber  tubes  passing  into 
the  larynx  and  out  through  the  tracheal  wound,  and  Hering's 
flexible  tubes  or  laryngo-tracheal  canulœ,  are  also  employed. 


Fig.  ii6. — Forceps  for  Extracting  the  Tubes. 

Surgical  treatment  may  also  be  resorted  to.  In  the  case 
of  simple  fibrous  strictures,  the  bistoury,  or  better  still  the 
galvano-cautery,  are  sufficient  ;  but,  if  the  constrictions  are 
more  extensive  and  really  tubular,  thyrotomy  should  be 
performed.  Once  the  larynx  is  opened,  and  the  constriction 
laid  bare,  the  fibrous  tissue  and  even  the  ventricular  bands 
may  be  resected. 

After  the  operation  a  tracheal  canula  will  ensure  respira- 
tion for  some  days.  In  case  of  need,  an  ordinary  tube,  fitting 
the  organ,  may  be  left  in  the  lar3mx.  For  this  purpose 
laryngo-tracheal  canulse,  T-shaped,  might  also  be  employed 
to  ensure  respiration  by  the  larynx  and  the  trachea,  and 
prevent,  by  means  of  the  glottic  tube,  recurrence  of  constric- 
tion.    The  apparatus  should  be  adapted  to  individual  cases. 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     225 

Some  authors  recommend  abstention  from  the  use  of  any 
endolaryngeal  medication  and  of  the  canula,  as  they  think 
that  all  those  foreign  bodies  only  irritate  the  wound  and 
postpone  its  cure,  and  may  cause  an  abundant  production 
of  granulations,  giving  rise  to  a  new  stenosis.  The  author 
advises  the  following  method  : 

Once  the  larynx  is  opened  (median  thyrotomy)  and  the 
fibrous  parts  resected,  the  thyroid  cartilage  should  be  imme- 
diately reunited,  the  cavity  being  left  without  plug  or  foreign 
body.  The  tracheal  canula  should  remain  in  position  for 
some  weeks  or  even  some  months. 

Laryngeal  Tuberculosis. 

Tuberculosis  of  the  larynx  may  be  classified  into  primary 
and  secondary,  according  as  it  precedes  or  follows  the  general 
affection,  and  into  acute,  subacute,  and  chronic,  according  to 
its  course. 

Etiology. — Tuberculosis  of  the  larynx  may  begin  either 
before,  after,  or  during  the  pulmonary  manifestations. 

Laryngeal  primary  tuberculosis,  formerly  denied  by  some 
authors,  is  now  recognized  by  most  laryngologists. 

The  laryngeal  manifestations  of  tuberculosis  may  occur  at 
any  stage  of  phthisis  pulmonaris,  and  do  not  necessarily 
correspond  to  it  in  its  evolution. 

Laryngitis,  designated  as  that  occurring  in  tuberculous 
people,  evidently  exists  as  a  simple  catarrhal  lesion  ;  but 
as  soon  as  ulceration  appears,  we  think  that  it  rapidly 
assumes  the  character  of  the  general  affection  in  becoming 
tuberculous. 

This  disease  seems  to  be  an  affection  specially  of  adults, 
occurring  chiefly  between  twenty  and  forty;  men  seem 
to  pay  a  larger  tribute  to  its  ravages  than  women,  as  it  is 
favoured  by  alcoholism  and  abuse  of  all  kinds  (tobacco,  etc.). 

Old  atrophic,  purulent,  or  ozasnic  coryza,  measles,  typhoid, 
and  influenza  predispose  to  tuberculosis. 

Pathogeny. — The  researches  of  Villemin  on  tuberculosis  and 
the  discovery  of  Koch's  bacillus  have  made  it  much  easier  to 
explain  the  localization  of  tuberculosis  in  the  larynx. 

15 


226  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

Bacilli  from  the  lungs  find  a  suitable  nidus  in  the  eroded 
and  even  ulcerated  or  inflamed  surface  of  the  larynx.  The 
larynx  is  more  frequently  affected  than  the  trachea,  as 
its  mucosa  is  more  exposed  to  inflammation.  Moreover, 
cough  and  expectoration  produce  an  energetic  friction  of  the 
cords,  capable  of  eroding  them,  and  favouring  ingress  to 
bacilli  proceeding  from  the  lungs.  In  patients  predisposed 
by  hereditary  taint  or  morbid  antecedents,  the  affection  may 
also  come  from  without. 

The  larynx  may  also  be  invaded  from  Vv'ithin  outwards  by 
bacilli  carried  by  the  blood  or  lymphatic  vessels. 

I.  FuN'CTioxAL  Symptoms — Voice. — x\t  the  catarrhal 
stage  the  patient  complains  specially  of  huskiness,  which 
very  rarely  attains  to  aphonia.  If  the  muscles  are  affected, 
the  vocal  disturbances  are  more  pronounced  ;  usualty  the 
timbre  is  merely  raucous,  husky,  or  bitonal. 

In  the  secondary  stage  the  voice  is  masked  and  tremulous, 
at  times  even  aphonic.  In  the  last  stage  it  is  completely 
muflled,  so  that  the  patient  whispers  rather  than  speaks. 

Disturbances  of  phonation  are  not  always  correlated  to 
changes  in  the  mucous  membrane.  Some  patients  may  be 
at  a  very  advanced  stage,  and  yet  have  an  intact  voice. 

The  vocal  alteration  may  be  due  to  catarrh,  to  thickening, 
to  ulcerations  of  the  cords,  to  infiltration  or  vegetations  in 
the  interarytenoid  region,  or  to  the  tumefaction  of  one  or 
both  ventricular  bands,  which  prevent  the  cords  coming 
together  or  vibrating.  Sometimes  the  vocal  cords  are 
entirely  destroyed,  yet  the  patient  continues  to  speak, 
owing  to  the  ventricular  bands  replacing  them.  The  voice 
has  then  a  masked  timbre.  Paralysis,  by  alteration  or  com- 
pression of  one  of  the  récurrents,  produces  chiefly  vocal 
bitonality. 

Pain — Deglutition. — At  the  primary  stage  pain  is  almost 
nil,  consisting  of  a  disagreeable  titillation,  which  causes  a 
spasm  of  coughing,  although  the  affection  of  the  larynx  is 
ver}^  slight,  being  limited  to  a  mere  redness  of  the  cord  and 
of  the  arytenoid  region.  During  the  secondary  period  pain 
and   dysphagia   are    more    pronounced,    as  the    ulcerations 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     227 

are  situated  more  externally  to  the  larynx — i.e.,  on  the 
epiglottis  and  arytenoid  region.  The  manifestations  in  the 
interior  of  the  larynx  are  almost  painless.  When  pain  does 
exist,  it  extends  to  the  ears,  and  is  generally  more  pronounced 
on  one  side  than  on  the  other. 

It  is  specially  during  the  tertiary  stage  that  pain  in  deglu- 
tition is  most  intense,  and  is  exasperated  on  each  movement 
of  the  organ,  owing  to  the  passage  of  the  food  over  inflamed 
or  ulcerated  surfaces,  and  also  to  the  friction  of  two  irritated 
and  swollen  mucous  membranes.  The  author  has  observed 
cases  in  which  dysphagia  was  a  sequence  of  osseous  hyper- 
trophies, originating  in  the  cricoid,  perforating  the  arytenoid 
mucous  membrane,  and  projecting  into  the  oesophagus. 

Considerable  pain  on  deglutition  may  coincide  with  a 
mere  œdem.atous  infiltration,  without  ulceration  of  the 
posterior  wall  of  the  lar3'nx.  It  is  then  caused  by  peri- 
chondritis or  crico-arytenoid  or  crico-thyroid  arthritis. 
The  propagation  of  the  pain  to  the  ears  is  explained  by 
Dr.  Beverley-Robinson  as  due  to  the  intimate  connection 
existing  between  the  ear  and  the  larynx,  as  the  sensory 
auricular  branch  of  the  superior  ganglion  of  the  vagus 
(Arnold's  filament)  innervates  the  auditory  meatus  and  the 
tympanic  membrane. 

The  deglutition  of  saliva  and  of  liquids,  especially  milk,  is 
more  painful  than  in  the  case  of  a  bolus,  and  the  patient 
complains  of  an  acute  burning  sensation  in  the  throat. 
Some  may  on  this  account  even  abstain  from  food. 

Phonation  and  coughing  are  only  painful  in  the  tertiary 
stage,  and  in  grave  ulcerous  and  advanced  forms. 

Except  in  the  case  of  cricoid  perichondritis,  the  larynx  is 
painless  to  the  touch.  Krishaber  and  Peter  have  for  long 
noticed,  that  the  cough  was  not  the  result  of  laryngitis  alone, 
but  rather  the  consequence  of  concomitant  pulmonary  affec  - 
tion,  as  in  primary  laryngeal  phthisis  this  symptom  is  com.- 
pletely  wanting.  Although  the  author  thinks  this  statement 
somewhat  sweeping,  it  is  certain,  that  cough  is  not  an  out- 
standing symptom  in  laryngeal  tuberculosis.  It  is  usually 
dry  and  short  at   the   beginning,  and  assumes    a   croupoid 

15—2 


2  28  DISEASES  OF  THE  PHARYNX  AXD  LARYXX 

character,  if  phenomena  of  recurrent  irritation  exist,  accom- 
panied by  a  sensation  of  itching.  The  accumulation  of 
mucus  on  the  posterior  region  or  on  the  edge  of  the  vocal 
cords  may  also  produce  '  hemming  '  rather  than  true  cough. 
On  the  contrary,  when  this  symptom  is  due  to  pulmonary 
lesions,  the  cough  follows  the  changes  of  the  voice,  being 
successively  sonorous,  raucous,  veiled,  or  jerky,  even  aphonic, 
often  of  a  belching  sound,  or  is  accompanied  by  efforts  of 
vomiting. 

Respiration,  normal  in  the  catarrhal  period,  may  be  inter- 
fered with  at  a  more  advanced  stage,  owing  to  the  immobility 
of  the  vocal  cords  by  crico-arytenoid  arthritis,  infiltration  of 
the  glottic  orifice  or  subglottic  region,  or  to  the  existence  of 
polypoidal  or  other  vegetations  in  the  larynx.  A  surgical 
operation  sometimes  becomes  necessary. 

Expectoration  depends  on  the  condition  of  the  lungs.  At 
the  outset  it  is  almost  nil.  Later  on  it  becomes  abundant, 
as  the  patient,  being  afraid  of  swallowing,  ejects  the  secre- 
tions. True  laryngeal  expectoration  is  sometimes  mucoid, 
muco-purulent,  purulent,  or  tinged  with  blood,  or  may  even 
contain  detritus  of  necrosed  cartilage.  It  is  very  difficult  to 
determine,  which  part  of  the  secretion  comes  from  the  larynx, 
or  if  it  only  passes  over  it. 

General  Symptoms  are  not  always  in  correlation  with 
the  laryngeal  lesion,  as  the  patient  may  have  a  comparativeh' 
good  appearance,  though  his  larynx  is  in  a  deplorable  con- 
dition. The  general  state  depends  more  on  the  pulmonary 
lesion  than  on  the  laryngitis,  but,  if  both  coincide,  the  patient 
rapidly  wastes. 

II.  Objective  Symptoms  —  i.  Primary  Catarrhal 
Period. — At  this  stage  of  bacillary  lar^mgitis,  laryngo- 
scopic  examination  reveals  lesions  which  considerably 
resemble  those  of  a  simple  acute  or  chronic  catarrhal 
inflammation.  In  some  cases,  however,  they  are  sufiicientl}' 
well  defined  to  indicate  the  commencement  of  laryngeal 
tuberculosis.  A  redness  of  a  carmine  hue  confined  to  the 
posterior  part  of  the  larynx,  on  the  arytenoids  or  vocal  cords, 
persisting  for  several  weeks  in  a  patient  already  run  down  in 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     229 


health,  patches  of  hypersemia  or  ecchymosis  disseminated 
in  the  lar3'nx  ;  sometimes  an  excessive  pallor  of  the  mucosa 
of  the  pharynx,  soft  palate,  and  larynx,  are  symptomatic  of 
tuberculosis.  These  lesions  are  frequently  associated  with  a 
verrucose  condition  of  the  interarytenoid  mucous  membrane. 
This  symptom  for  a  long  time  has  been  considered  as  of  capital 
importance,  and  of  almost  pathognomonic  importance,  but 
has  lost  much  of  its  significance  since  the  lesions  of  the 
larynx  have  become  better  known.  This  verrucose  condi- 
tion occurs  in  laryngitis  accompanying  either  atrophic  coryza 
or  some  arthritic  anginae. 

If  the  interarytenoid  mucous  membrane  appears  almost 
polypoid,  showing  greyish  papillary  projections  separated  by 


Fig.   117. — Bacillary  Laryn- 
gitis (Catarrhal  Period). 


Fig.  118. — Tuberculous  Laryngitis 
(Second  Stage). 


furrows,  and  if  infiltration  is  observed  in  the  interarytenoid 
mucous  membrane  or  the  aryepiglottic  folds,  incipient 
bacillary  laryngitis  is  suggested. 

The  concomitant  presence  of  erosions  clearly  points  to 
bacillary  laryngitis. 

2.  Secondary  Period:  (a)  Circumscribed  Œdema- 
tous  Form. — At  this  stage  it  is  usual  to  observe,  either  a 
redness  confined  to  a  part  of  the  larynx,  or  a  diffuse  pallor. 
The  posterior  or  interarytenoid  region  is  seldom  unaffected, 
and  shows  a  velvety  papillary  appearance. 

At  the  same  time  infiltration  appears  at  the  level  of  one 
of  the  arytenoids  and  of  the  corresponding  folds.  Some- 
times only  one  vocal  cord  is  affected.  It  is  increased  in 
bulk,  becomes  rugose  and  granular,  with  small   superficial 


230  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

indentations  (corditis  vocalis  inferior).  The  ventricular  band 
may  also  be  similarly  affected,  but  the  epiglottis  is  usually 
spared.  At  other  times  the  lesion  is  somewhat  more  diffuse, 
the  infiltration  occupying  almost  the  whole  posterior  region 
of  the  larynx.  The  vocal  cords  are  merely  red  or  a  little 
swollen,  and  present  on  their  free  edges  or  posteriorly  super- 
ricial  ulceration.  True  granular  ulcers  with  greyish  bases 
occupy  the  corresponding  portion  of  the  ventricular  band, 
or,  more  rarely,  the  laryngeal  surface  of  the  epiglottis.  The 
latter  is  generally  unaffected  ;  the  aryepiglottic  folds  are 
scarcely  infiltrated.  It  is  evident  here  that  we  are  in  the 
presence  of  hard  localized  œdema  described  by  Gougenheim 
and  Tissier  under  the  name  of  hypertrophic  sclerema. 

In   certain    forms    posterior   infiltration  is    comparatively 


Fig.  119.— Bacillary  Laryngitis  (Second  Period). 

Ulceration  and  pachydermia  degeneration  of  the  epiglottis  and  of  the 
interior  of  the  lar5-nx. 

slight,  and  the  affection  seems  to  be  limited  to  the  vocal 
cords,  which  become  red,  granular,  and  swollen.  The 
ventricular  mucous  membrane,  infiltrated  and  projecting, 
partly  covers  the  underlying  cords.  The  cords  present 
mesially,  either  on  the  upper  surface  or  on  their  free  edge, 
small  ulcers,  the  prominent  parts  of  one  filling  into  the 
depression  of  the  other.  In  this  case  phonation  is  deeply 
affected,  because  the  thyro-arytsenoideus  is  more  or  less 
paretic. 

(b)  Diffuse  Ulcero-œdematous  Form. — This  con- 
stitutes typical  laryngeal  tuberculosis,  whether  the  infection 
originates  in  the  larynx  or  is  consequent  to  pulmonary 
lesions.  The  parts  of  the  mucous  membrane  most  frequently 
affected    are   those   of   the    arytenoid    region,    vocal   cords, 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX    231 

ventricular  bands,  aryepiglottic  folds,  epiglottis,  and  sub- 
glottic region.  The  lesions  of  the  arytenoid  region,  which 
are  never  absent,  are  sometimes  symmetrical,  but  most  fre- 
quently are  more  pronounced  on  one  arytenoid  than  on  the 
other.     The   aryepiglottic   folds,   unequally  filtrated,  give   a 


Fig.   120. — Diffuse  Ulcero-œdematous  Bacillary  Laryngitis. 

deviated  appearance  to  the  larynx.     They  assume  a  pyriform 
shape. 

Each  of  the  ventricular  bands  is  transformed  into  a  some- 
what indefinite  ridge.  The  swelling  may  became  so  pro- 
nounced,  that   it  reaches   the  ventricles   of   Morgagni,   the 


Fig.   121. — Tuberculous  Laryngitis. 


aperture  of  which  disappears,  and  varieties  of  pseudo- 
inversion  of  the  mucosa  are  formed.  (Those  have  been 
erroneously  termed  by  authors  ventricular  eversion.  It  is 
now  known,  that  the  mucosa  of  the  ventricle  may  be  so 
swollen,  as  to  cover  totally  or  partly  the  subjacent  vocal 
cord,    but    it    is    in    no    case    detached    from    the    thyroid 


232  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

cartilage  to  become  inverted  into  the  larynx.)  When  the 
swelling  reaches  the  epiglottis,  the  infiltration,  sometimes 
limited  to  the  lingual  surface,  gradually  subsides  towards 
the  free  edge,  which  becomes  more  or  less  thickened.  Most 
frequently  the  tumefaction  is  general  and  causes  immobility 
and  deformity  of  this  organ,  which  extends  to  five  or  six 
times  its  normal  size. 

At  this  stage  ulceration  is  also  observed,  disseminated 
here  and  there,  but  chiefly  on  the  posterior  surface  of  the 
ventricular  bands,  the  vocal  cords,  the  epiglottis,  and  the 
arytenoid  region.  These  ulcers,  generally  flattened  and 
crateriform,  are  very  superficial  at  the  outset,  and  their  edges 
blend  gradually  into  the  healthy  parts,  but  at  a  later  stage 


Fig.  122. — Tuberculous  Laryngitis  (Diffuse  Form). 

The  epiglottis  is  swollen  ;  the  arytenoid  region  and  the  cords  are 
tumefied  and  ulcerated. 

they  are  easily  recognized  by  their  greyish  and  anfractuous 
surface,  their  more  projecting  and  even  ragged  edges.  These 
losses  of  substance  are  almost  always  multiple,  disseminated 
over  the  whole  larynx,  without  a  well-defined  line  of  demarca- 
tion. On  the  epiglottis  they  usually  occupy  the  free  edge 
or  the  lingual  surface.  In  the  larynx  they  are  confined  to 
the  arytenoids  or  the  ventricular  bands.  Sometimes  they 
reach  the  subglottic  region.  In  that  case  the  mucosa  of 
the  region  projects  under  the  vocal  cords,  and  forms  two 
ridges,  obstructing  the  respiratory  orifice.  Three  or  four 
different  planes  are  then  formed,  from  above  downwards  : 
the  ventricular  bands  ;  the  mucosa  of  the  swollen  ventricle  ; 
the  red,  eroded,  or  ulcerated  vocal  cord;  and  the  subglottic 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     233 

mucosa.  When  these  alterations  have  deeply  invaded  the 
epiglottis,  it  resembles  a  shapeless  mass,  with  irregular 
and  anfractuous  edges,  and  is  almost  immobile.  The  colora- 
tion of  the  mucous  membrane  varies  according  to  the  general 
state  of  the  patient — sometimes  red,  sometimes  pale  and 
greenish,  and  the  membrane  is  often  covered  by  mucus  or 
purulent  secretion,  which  should  be  removed  by  coughing  or 
by  the  cotton-wool  mop. 

Towards  the  end  of  this  stage  there  may  supervene  crico- 
arytenoid arthritis,  which  is  distinguished  by  a  peri-articular 
swelling  and  immobility  of  the  corresponding  vocal  cord. 

It  is  possible  for  arthritis  to  occur  on  both  sides  of  the 


Fig.   123. — Tuberculous  Laryngitis,  with  Dermo-papillary  Pachy- 
DERMIC  Degeneration  of  the  Interarytenoid  Region. 


larynx,  and  then  cause  asphyxia  by  glottic  stenosis,  unless 
destructive  ulceration  of  the  mucosa  enlarges  the  orifice,  and 
permits  the  air  to  penetrate  into  the  lungs. 

Gougenheim  and  Tissier  have  also  well  described  paralysis, 
(myopathic  or  by  compression  of  the  récurrents),  which  may 
be  observed  at  this  period  of  the  affection.  The  dyspnœic 
disturbances  undoubtedly  assume  great  intensity  in  this 
form. 

(c)  Vegetative  Form. — In  slow  and  chronic  forms 
laryngeal  tuberculosis  is  indicated  by  warty  tumours,  of 
unequal  size  and  having  a  large  base.  These  local  hyper- 
trophies are  sharp -pointed,  occupy  the  interarytenoid  space, 
and  project  into  the  glottic  cavity,  which  they  partly  conceal. 


234  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

They  are  either  large  anfractuous  granulations,  between 
which  the  secretions  remain  and  dry  up,  or  true  tuberculous 
vegetations  with  a  polypoid  appearance,  which  almost 
entirely  choke  the  glottic  orifice.  In  slight  cases  it  is  merely 
a  question  of  warty  lesions  of  a  rosy  gray,  cuneiform  appear- 
ance projecting  at  the  level  of  the  posterior  wall.  These 
warty  growths  may  also  originate  on  the  ventricular  bands, 
the  base  of  the  ventricles,  or  even  on  the  ulcerated  cords, 
constituting  true  pedunculated  polypoid  tumours,  which 
closely  resemble  an  ordinary  polypus  of  the  larynx,  from 
which  they  differ  by  the  coexistence  of  lesions  on  the  posterior 
region  and  the  concomitant  deformity  of  the  organ.  These 
vegetative  masses  may  vary  in  site,  bulk,  and  appearance, 
but  the  posterior  region  is  almost  always  affected. 

This  species  of  fungous  interarytenoid  tuberculosis  appears 
to  the  author  to  be  common,  not  only  in  former  syphilitic 
patients,  drunkards,  smokers,  in  those  who  snuff  or  live 
among  dust,  but  more  particularly  in  the  case  of  those  affected 
with  ozjenic  atrophic  cor3-za  or  its  derivatives. 

3.  Tertiary  Period. — The  papillary  condition  of  the 
region  being,  so  to  speak,  classic  in  atrophic  laryngitis  of 
oogenic  origin,  it  is  not  surprising  to  see  it  even  more  pro- 
nounced in  subjects  affected  with  laryngeal  tuberculosis  of 
slow  development. 

Gougenheim  and  Glover  have  demonstrated  the  existence 
of  true  tuberculous  pedunculated  polypi  in  patients  showing 
only  slight  signs  of  pulmonary  tuberculosis,  and  even  free 
from  all  appreciable  bacillary  alteration,  perceptible  b}'  per- 
cussion or  auscultation. 

These  tumours  usually  recur  after  their  removal,  and 
histological  examination  alone  permits  of  their  tuberculous 
nature  being  recognized. 

This  stage,  in  which  the  disease  is  practically  hopeless,  is 
characterized  by  caries  and  necrosis,  the  various  lesions 
blending  together.  This  is  the  stage  of  perichondritis  follow- 
ing on  alterations,  which  have  penetrated  deeph',  and  give 
rise  to  necrosis  of  the  cartilages.  In  some  rapid  forms  the 
arytenoids  and  the  cartilages  of  Wrisberg,  even  a  part  of  the 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     235 

cricoid,  may  become  necrosed  and  cast  off,  whereas  in  slower 
forms  points  of  ossification  or  even  true  osteophytes  are 
observed,  as  well  as  circumscribed  or  diffused  abscesses 
opening  round  the  thyroid  lamina  anteriorly  and  laterally. 

Later,  one  or  several  external  fistulse,  communicating  with 
a  part  of  the  necrosed  thyroid,  are  formed.  The  larynx  col- 
lapses,  becoming   completely  deformed.     The    aryepiglottic 


Fig.  124.  —  Tuberculous  Laryngitis  at  the  Third  Stage,  with 
Perichondritis  of  the  Posterior  Portion  of  the  Cricoid,  and 
Production  of  a  True  Osteophyte  perforating  the  Œsophageal 
Mucosa. 


folds  are  transformed  into  enormous  ridges,  covered  with 
extensive  greyish  miliary  ulceration,  continuous  with  the 
ulceration  of  the  base  of  the  glottis  and  that  of  the  tongue. 
The  whole  organ  is  filled  with  greyish,  purulent,  often 
fetid  secretions,  which  are  ejected  with  acute  pain,  and  the 
functional  disturbances  then  attain  their  maximum  intensity. 
Not  only  is  the  patient  aphonic,  but  dysphagia  has  become 
so  marked,  that  food  is  often  refused.     Respiration  is  very 


236 


DISEASES  OF  THE  PHARYNX  AND  LARYNX 


painful  owing  to  laryngeal  stenosis,  and  particularly  to  the 
breaking  down  of  the  pulmonary  tissue,  and  the  general  state 
of  the  patient  foreshadows  a  fatal  result. 

Pathological  Anatomy. — Tuberculosis  of  the  larynx  does  not 
differ  from  that  of  other  organs.  It  is  characterized  by 
tuberculous  deposits,  with  tumefaction  or  ulceration  of  the 
mucous  membrane.  Œdematous  infiltration  is  one  of  the 
most  constant  lesions.  It  appears  after  death  as  a  smooth, 
pasty,  indurated  swelling,  covered  with  a  pale,  rough,  rugose 


Fig.   125.^ — Appearance  of  an  Opened  Tuberculous  Larynx 
(Tertiary  Stage  :    Ulcero-necrotic). 

mucous  membrane,  sometimes  spread  over  with  caseous 
granulations.  In  slow  forms  the  œdema  is  hard,  and  the 
tissues  more  compact  (sclerema).  Microscopic  examination 
shows  under  the  epithelial  layer  of  the  mucous  membrane 
an  abundant  cellular  infiltration.  Tuberculous  nodules  are 
also  found  under  the  epithelium,  but  not  in  the  tissue  situate 
between  the  bacillary  deposit  and  the  epithelium,  which  con- 
tains rounded  cells  and  many  bloodvessels.  This  suggests 
that  the  ulceration  takes  place  from  within  outwards. 
Bacilli  are  rare  in  tuberculous  granulations. 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     237 

The  vocal  organs  are  considerably  affected.  The  glands 
may  be  implicated  either  primarily  or  secondarily,  the  tissue 
surrounding  them  being  destroyed,  and  the  tuberculous 
infiltration,  penetrating  between  the  acini,  compresses  and 
causes  them  to  disappear.  At  the  tertiar}^  stage  the  cartilage 
itself  is  more  or  less  ossified  or  necrosed.  The  perichon- 
drium contains  many  purulent  cells,  surrounding  the  fibro- 
cartilage,  so  that  it  becomes  softened  and  undergoes  fatty 
degeneration,  unless  it  becomes  ossified  or  necrosed. 

The  coats  of  the  bloodvessels  are  destroyed  by  tuberculous 
infiltration.  The  muscles  are  rarely  penetrated  by  tubercle, 
but  are  infiltrated  by  round  cells,  and  their  contractile  sub- 
stance is  transformed  into  a  fine  molecular  mass. 

The  epithelium  is  sometimes  unaffected.  Most  frequently 
it  is  infiltrated,  and  disappears,  laying  bare  portions  of 
the  mucous  membrane  in  which  ulceration  originates.  A 
tuberculous  ulcer  is  characterized  by  the  presence  of  tubercles 
on  its  edges  or  base.  It  may  be  considered  as  such,  when 
giant  cells  are  found  in  it,  forming  a  diffused  or  circum- 
scribed infiltration  in  the  connective  tissue. 

Ulcerations  vary  in  form  and  in  size,  according  to  whether 
they  are  the  result  of  infiltration  or  of  small  isolated  miliary 
tubercles.  In  the  latter  case  the  ulcers  are  superficial  and 
non-confluent  at  the  outset. 

These  losses  of  substance  (aphthous  patches)  are  generally 
found  where  the  mucous  membranes  are  least  adherent,  and 
at  the  level  of  the  ventricular  bands  and  their  inferior 
surface. 

In  the  other  forms  the  ulcers  are  deep,  crateriform,  with 
loose  edges,  greyish  base,  and  covered  with  pus,  muco-pus, 
01  ichorous  secretions.  The  mucous  membrane  is  punc- 
tured with  small  perforations,  '  presenting  an  ethmoidal 
appearance'  (Schech). 

The  papillary  vegetations,  which  are  observed  especially 
at  the  level  of  the  interar3/tenoid  region,  are  usually  an 
integral  part  of  tuberculosis  ;  but  it  has  been  proved  lately, 
that  they  exist  in  syphilis,  epithelioma,  laryngitis,  sicca,  or 
ozaenic  coryza. 


238  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

Course — Duration. — The  course  of  laryngeal  tuberculosis  is 
very  variable. 

Generally  the  vocal  lesion  follows  the  evolution  of  the 
pulmonary  affection.  Primary  vocal  tuberculosis  may  remain 
stationary  for  a  long  time  ;  but,  when  the  pulmonary  lesions 
develop,  the  patient  may  rapidly  succumb. 

Tuberculous  laryngitis  is  more  rapid  in  younger  subjects, 
especially  if  any  predisposition  exists,  and  is  slower  between 
the  ages  of  thirty  and  fifty. 

Termination. — In  slow  forms  local  lesions  may  be  cured 
by  well-directed  treatment,  but  in  those  rare  cases  the 
patient  must  be  watched  for  years,  as  recurrence  is  very  apt 
to  take  place.  Death  usually  occurs  from  aggravation  of 
pulmonary  and  laryngeal  lesions,  from  emaciation,  cachexia, 
or  from  glottic  stenosis. 

Prognosis.- — -With  Gottstein,  the  author  believes,  that 
nothing  can  withstand  tubercular  onsets  of  the  larynx,  when 
pulmonary  tuberculosis  is  virulent.  The  existence  of  ulcera- 
tion and  infiltration  is  always  a  grave  prognosis,  but 
tuberculous  ulceration  has  been  cured  by  a  combined 
local  and  general  treatment,  and  sometimes  by  the  latter 
alone. 

As  everybody  now  admits  the  curabilit}'  of  the  disease,  the 
prognosis  is  less  grave. 

The  diathesis  of  the  patient  pla3-s  an  important  rôle,  both 
as  regards  the  disease  and  its  treatment.  The  natural 
tendency  of  the  tubercle  is  to  become  fibrous,  being  opposed 
to  cancer  in  that  respect.  Each  tubercle  undergoes  two 
distinct  processes — caseation  in  the  centre  and  fibrosis  at 
the  periphery.  If  the  former  predominates,  the  tissue  breaks 
down;  but,  on  the  other  hand,  if  the  formation  of  fibrous 
tissue  is  complete,  recovery  ensues  from  the  isolation  of  the 
affected  area. 

When  the  ulceration  is  extensive  and  deep,  the  case  may 
be  considered  hopeless,  especially  if  pulmonary  lesions  are  at 
an  advanced  stage. 

When  general  nutrition  is  interfered  with,  and  the  affection 
proceeds  by  a  succession  of  acute  onsets,  a  fatal  issue  usually 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     239 

follows.  It  must  be  remembered,  that  a  patient,  for  years 
considered  cured,  may  relapse  and  succumb. 

Curable  cases  seem  to  be  those  in  which  tuberculosis 
slowly  develops,  without  inflammator}-  onsets,  and  in  which 
the  local  lesions  are  always  isolated. 

Death  is  generally  the  rule,  when  the  patient  has  reached 
the  tertiary  period. 

Diagnosis. — The  preceding  symptoms,  although  constitut- 
ing valuable  indications,  are  not  alwa3'S  sufficient  to  deter- 
mine the  diagnosis.  In  many  cases,  indeed,  examination  of 
the  lungs  gives  a  doubtful  or  negative  result.  Resort  must 
then  be  made  to  larjmgoscopic  examination,  which  ^^•ill  reveal 
persistent  anaemia  of  the  vocal  mucosa  and  disturbances  of 
mobility  at  the  onset  of  laryngeal  tuberculosis.  In  simple 
catarrhal  laryngitis  the  vocal  cords  appear  rough  and 
reddened,  but  there  is  neither  swelling  nor  ulceration  at  the 
level  of  the  arytenoid  region.  The  author  does  not  consider 
the  velvety  appearance  to  be  symptomatic  of  bacillosis.  The 
evolution  of  the  malady,  its  slow  but  progressive  course,  its 
resistance  to  the  usual  local  treatment,  will  dispel  the  idea  of 
simple  catarrh. 

Persistent  redness,  with  slight  infiltration  of  the  arytenoid 
region,  suggests  tuberculosis.  Syphilis  during  the  secondary 
period  may  also  cause  an  erythema,  and  even  erosions,  on 
the  edge  of  the  vocal  cords  ;  but  usually  those  morbid 
changes  are  accompanied  by  analogous  manifestations  in  the 
pharyngeal  cavity,  the  tonsils,  and  the  lips,  of  characteristic 
roseola,  and  polyadenitis. 

Circumscribed  ulcero-cedematous  laryngitis  cannot  be  con- 
fused with  tertiary  S3'philitic  ulcerations,  as  those  usually 
appear  on  perfectly  healthy  subjects,  and  are  accompanied 
by  huskiness  of  the  voice  and  cough.  Moreover,  the  specific 
loss  of  substance  is  usually  painless,  or  nearly  so. 

In  tuberculosis  the  ulceration  is  more  superficial,  and  diffuse, 
and  the  infiltration  paler  than  in  syphilis.  In  the  latter  the 
swelling  is  localized  in  one  side  of  the  larynx — often  on  one 
ventricular  band  or  vocal  cord.  The  subglottic  region  is 
red,  and  even  ulcerated,  the  posterior  portion  being  spared. 


240   ■       DISEASES  OF  THE  PHARYNX  AND  LARYNX 

In  syphilis  tumefaction  is  rapidly  followed  by  an  anfractuous, 
irregular,  even  serpiginous  ulceration  of  crateriform  shape, 
with  projecting  edges,  which  rapidly  gains  in  breadth  and 
depth  if  not  arrested.  In  a  word,  the  course  of  syphilis  is 
quicker,  often  even  rapid,  whereas  that  of  tuberculosis,  except 
in  the  acute  form,  is  slow,  and  ulcerations,  if  present,  are 
confined  to  a  part  of  the  larynx. 

In  diffuse  ulcero-cedematous  forms  diagnosis  is  generally 
easier,  on  account  of  the  extent  of  the  lesions,  syphilis  being 
characteristically  confined  to  a  part,  whence  it  radiates  in 
different  directions.  The  mode  of  the  formation  of  those 
two  lesions  is  also  fairly  distinct.  The  tuberculous  ulcer 
begins  usually  in  circumscribed  spots,  which  gradually  blend 
together  and  form  confluent  ulcers.  In  syphilis  the  loss  of 
substance  is  usually  single,  of  a  more  or  less  extensive  area, 
and  gains  in  depth. 

When  the  epiglottis  is  affected  by  syphilis,  the  base  of  the 
tongue,  and  often  the  pharyngeal  wall,  are  almost  always 
involved. 

To  sum  up,  tuberculosis  invades  the  larynx  irregularly  and 
diffusely.  Syphilis,  on  the  other  hand,  is  confined  as  a  rule 
to  one  half  of  the  larynx,  particularly  to  the  ventricular 
bands  and  the  subglottic  region.  Yet  a  syphilitic  subject  may 
be  affected  with  tuberculosis,  and  the  symptoms  be  combined. 

Generally  the  development  of  tuberculosis  in  the  lungs,  and 
the  appearance  of  other  syphilitic  changes  on  the  skin  and  in 
the  pharynx,  facilitate  the  diagnosis.  In  doubtful  forms, 
curetting  of  the  tuberculous  ulcer  and  bacteriological 
examination  will  settle  the  question. 

Vegetative  tuberculosis  can  be  confused  only  with  polypi 
of  the  lar3'nx,  but  the  latter  occur  in  healthy  subjects, 
and  project  from  a  normal  mucosa.  The  polypoid  growths 
of  bacillary  laryngitis  are  almost  always  accompanied  by  loss 
of  substance,  or  at  least  by  characteristic  infiltration. 

In  the  pseudo-polypoid  form  histological  examination  will 
determine  the  nature  of  the  neoplasm.  The  author  does  not 
consider  it  necessary  to  make  a  differential  diagnosis  between 
ulceration    of    tuberculosis    and   malignant   tumours.     The 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     241 

latter  present  such  clear  characteristics  that,  at  least  in  the 
classic  form,  confusion  should  never  occur. 

Vocal  paralysis  at  the  outset  of  tubercular  laryngitis  might 
be  confused  with  motor  disturbances,  consequent  on  pressure 
on  the  afferent  nerves  or  the  vagus. 

In  the  latter  instance  paralysis  is  almost  always  unilateral, 
or  at  least  begins  on  the  one  side.  Further,  it  may  be 
observed,  that  in  vocal  tuberculosis  the  swollen  glands,  or  the 
apex  of  the  infiltrated  right  lung,  compress  the  nerves  of  the 
larynx,  and  immobilize  the  vocal  cord. 

In  the  last  stage  of  laryngeal  phthisis  paralysis  is  due  more 
to  a  lack  of  sufficient  air  to  cause  vibration  of  the  cords,  than 
to  true  loss  of  mobility  ;  yet  the  degenerated  muscles  of  the 
larynx  may  be  unable  to  adduct  the  cords. 

Treatment. — Treatment  of  laryngeal  tuberculosis  has  been 
considerably  simpHfied  of  late.  General  treatment  should 
have  the  premier  place  in  this,  as  in  pulmonary  tuberculosis. 

Prophylactic  treatment  of  patients  affected  with  pulmonary 
tuberculosis  should  consist  of  hygienic  precautions.  The 
patient  should  not  be  permitted  to  smoke,  or  stay  in  rooms 
with  irritating  dust  or  tobacco-smoke.  He  should  use  his 
voice  moderately. 

When  the  affection  has  invaded  the  vocal  mucosa,  the 
air-cure,  rest,  and  overfeeding,  should  be  prescribed  and 
rigorously  administered.  The  air-cure  should  be  judiciously 
carried  out  at  first,  the  patient  being  got  gradually  accus- 
tomed to  sleep  with  open  windows. 

Local  treatment  varies  according  to  the  stage,  and 
especially  to  the  form  of  the  disease.  Each  case  should  be 
treated  according  to  individual  requirements.  During  the 
catarrhal  stage  inhalations  of  volatile  substances,  such  as 
balsam  of  Peru,  tincture  of  eucalyptus,  tar,  menthol,  may  be 
prescribed.     The  following  prescription  is  recommended  : 

i\  Pulverized  menthol         ...     2  to  5  grammes     gr.  30  to  75 
Balsam  of  Peru  ...     4  to  10       ,,  3i  to  iiss 

Tincture  of  eucalyptus    ..       250  ,,  gviii 

Put  T  teaspoonful  of  this  mixture  in  |   litre  of  hot  water 


242 


DISEASES  OF  THE  PHARYNX  AND  LARYNX 


for  inhalation  for  five  to  ten  minutes,  morning  and  evening. 
The  inhalations  must  be  at  first  lukewarm,  and  then  as  hot 
as  the  patient  can  bear  them. 


Fig.  126.— Steam  Spray  (Small  Model). 


Sprays  of  carbolic  acid,  boric  acid,  benzoate  of  soda,  borax, 
etc.,  may  replace  the  inhalations. 

The  author  generally  advises  the  following  formula  : 

li  Carbolic  acid 
Benzoate  of  soda 
Tincture  of  eucalyptus 
Glycerine  (neutral) 
Water  (distilled) 

Or— 

li  Benzoate  of  soda 
Resorcin 

Glycerine  ^ 

Cherry-laurel  water) 
Water    ... 

This  is  to  be  used  twice  or  thrice  daily,  according  to  the 
intensity  cf  the  inflammation,  for  five  minutes  at  a  time. 
At  this  stage  any  erosions  should  be  touched  with  solution 


6  centigrammes 

gr.  90 

6  grammes 

gr.  go 

10 

ni^clx 

40 

.'îlX 

■       450 

gxvi 

6  grammes 

gr.  90 

4 

gr.  60 

f    0X1 

aa  50 

iSxiii 

..     400 

oxiv 

DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     243 

of  zinc  chloride  (i  :  50  or  i  :  60)  every  eight  or  ten  days  or 
so,  or  silver  nitrate  (i  :  50,  i  :  30,  or  even  i  :  20). 

Cauterization  should  be  used  very  occasionally,  or  avoided, 
if  it  irritates  the  mucous  membrane  too  much. 

During  the  secondary  stage  in  inflammatory  forms,  treat- 
ment should  be  only  palliative  and  antiphlogistic,  and  should 
consist  of  counter -irritation,  blistering,  ignipuncture  on 
the  side  of  the  larynx,  or  sedatives,  inhalation,  or  sprays, 
according  to  the  above  formulae,  and,  above  all,  absolute  rest 
of  the  voice. 

If  the  lesions  occupy  the  glottis  or  the  posterior  region — 
that  is  to  say,  if  they  are  extralaryngeal — gargles  and  throat- 
washes  should  be  used,  according  to  the  following  formula, 
which  is  both  sedative  and  antiseptic  : 

1]l   Iodine  ) 

T    ,.,       r      ^      ■       ,-     ••■        aa  3  centigrammes     aa  gr.  5 
Iodide  01  potassium)  ^  » 

Carbolic  acid  ...  3  grammes  gr- 45 

Laudanum  (Sydenham's)  4         ,,  ]\\x 

Glycerine  (neutral)        ...  150  ,,  siv 

A  teaspoonful  of  this  liquid  in  a  glass  of  tepid  water  as 
a  throat-wash  three  or  four  times  daily. 

If  the  gargle  is  too  disagreeable,  and  does  not  prove  bene- 
ficial, the  following  may  be  used  : 


àâ  5         „  ââ  gr.  75 


li  Carbolic  acid  ...  ...  3  grammes         gr.  45 

Bromide  of  potassium) 
Antipyrin  j 

Laudanum  (Sydenham's),  or 

tincture  of  eucalyptus  ...  5         ,,  IT^lxxx 

Glycerine   ...  ...  ...       150        „  siv 

Add  a  spoonful  of  this  mixture  to  a  glass  of  tepid  water,  and 
bathe  the  throat  daily.  If  need  be,  add  0*5  centigramme  to 
I  gramme  of  hydrochloride  of  cocaine  as  an  anaesthetic. 

Direct  application  should  be  avoided  during  the  inflam- 

16 — 2 


244 


DISEASES  OF  THE  PHARYNX  AND  LARYNX 


matory  stage,    as   it    is    too    irritating.      At    most    a   small 
quantity  of  finely-powdered   iodoform,   or   a   pinch    of  the 


Fig.  127. — Laryngeal  Powder  Insufflator.     (Moure.) 

following  powder  can   be  used  as   an   insufflation   into  the 
larynx  : 

^.  Hydrochloride  of  cocaine         50  centigrammes         gr.  yh 
Pulverized  menthol  ...  i  gramme  gr.  15 

Iodoform,  or  biniodoform 


Boric  acid 


aa  5  grammes 


aa  gr.  75 


This  insufflation  should  be  performed  daily  or  every  second 
day.     A  solution  of  iodoformed  ether,  with  a  certain  quantity 


Fig.  128. — Metal  or  Vulcanite  Powder  Insufflator. 


of  menthol,  might  also  be  used  to  disguise  the  disagreeable 
odour  of  the  iodoform. 


25  centigrammes 

gr.  4  to  16 

to  I  gramme 

àà  4  grammes 

ââ  gr.  60 

40 

ôix 

10 

niclx 

450 

5xvi 

DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     245 

Instillations  of  oily  substances  may  also  be  substituted  or 
alternated  with  the  preceding  powder. 

1^  Oleate  of  cocaine  ...  50  centigrammes  gr.  7^ 

Guaiacol           ...  ...          i  gramme  n\^xv 

Menthol           ...  ...          2  grammes  gr.  30 

Liquid  vaseline  oil  ...  60         ,,  §ii 

In  the  slow  and  ulcerous  forms  the  antiseptic  inhalations 
and  spra3's  of  the  iirst  stage  could  be  employed.  If  dys- 
phagia exists,  they  may  be  modified  as  follows  : 

R  Hydrochloride  of  cocaine 

Antipyrin  ^ 

Bromide  of  potassium  I 

Glycerine 

Spirit  of  peppermint 

Water  (distilled) 

To  be  used  once  or  twice  daily  for  five  minutes  at  most. 

Cocaine  could  be  replaced  either  by  carbolic  acid  or  beech 
creosote. 

Cicatrization  and  retrogression  of  the  infiltration  areas 
should  be  assisted.  To  that  end  some  specialists  recom- 
mend a  very  active  local  application  with  nitrate  of  silver, 
chromic  acid,  tincture  of  iodine,  chloride  of  zinc,  in  full 
doses.  Others,  on  the  contrary,  recommend  either  total 
abstention  or  a  mild  treatment,  believing  that  caustics  are 
apt  to  aggravate  the  disease,  instead  of  effecting  a  cure. 

Astringents  are  generally  more  efficacious  than  caustics. 
Chloride  of  zinc  and  nitrate  of  silver  in  weak  solution  and 
carbolic  acid  may  be  applied  in  the  larynx  from  time  to  time. 

Ruault  has  recommended  sulphoricinic  acid,  neutralized 
with  soda  ;  but  the  author  prefers  glycerine,  as  it  has  exactly 
the  same  effect,  is  more  easily  procurable,  is  by  no  means 
toxic,  is  ansesthesic,  and  holds  in  solution  a  considerable 
amount  of  carbolic  acid.  This  may  be  used  in  strengths 
varying  from  i  :  30,  i  :  20,  i  :  10,  i  :  5,  or  i  :  3. 


246 


DISEASES  OF  THE  PHARYNX  AND  LARYNX 


Solution  of  naphthol  or  salol  (i  :  10  or  i  :  15)  could  also 
be  used,  dissolved  in  soda  sulphoricinate. 

Iodoform  and  biniodoform  in  ether  solution,  or  in  emul- 
sion with  glycerine,  have  the  effect  of  forming,  as  it  were,  a 
varnish  on  the  surface  of  laryngeal  wounds.  Orthoform  and 
the  solution  of  iodine  and  carbolic  already  indicated  should 
prove  an  excellent  application. 

Surgical  Treatment. — Krause  and  Hering  have  advised 
surgical  treatment  of  the  ulcerated  surfaces  in  tuberculous 
laryngitis  after  cocainization  of  the  larynx.     The  ulcerations 


Fig.  129.  —  Intralaryngeal,  Pharyngeal,  or  Nasal  Spray,  with 
Liobett's  Attachment,  serving  for  Cocaine,  Iodoformed  Ether, 
and  other  Liquids. 


are  curetted,  and  the  raw  surface  energetically  swabbed  with 
a  solution  of  lactic  acid  (i  :  4  or  i  :  3),  and  then  with  half- 
diluted  or  even  pure  acid. 

Submucous  anaesthesia  is  obtained  by  means  of  the  follow- 
mg  formula  : 


li  Hydrochloride  of  cocaine 

Carbolic  acid  solution  (2  :  100) 


25  centigrammes       gr.  4 
2' 50  grammes  ll\_xl 


Inject  3  or  4  minims  in  one  or  two  areas,  according  to  the 
degree  of  anaesthesia  desired.  The  author  is  of  opinion,  that 
the  above  formula  is  somewhat  too  concentrated. 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     247 

Hering  thought  that  the  preliminary  anaesthetization  of 
the  mucous  membrane  was  of  paramount  importance,  and 
that  the  omission  of  that  precaution  was  the  source  of  the 
want  of  success  associated  with  that  method. 


Fig.  130.  — Series  of  Laryngeal  Instruments  adaptable  to 
Common  Handle. 

O,  Lever  handle  ;  E,  small  polypotome  guillotine  ;  F,  large  polypotome 
guillotine  ;  G,  G',  two  scarifiers  (pointed  and  blunt)  ;  A,  ordinary  forceps  ; 
B,  forceps  acting  from  above  downwards;  C,  cutting  forceps;  J,  punch 
forceps  acting  from  above  downwards  ;  K,  L,  two  punch  forceps  acting 
laterally  (large  and  small)  ;  H,  antero-posterior  punch  forceps  ;  D,  N,  two 
pairs  of  laryngeal  scissors  (straight  and  curved);  M,  laryngeal  snare; 
I,  platinum  porte-caustic. 

According  to  the  author,  lactic  acid  is  an  excellent  remedy, 
but  is  somewhat  liable  to  occasion  spasm.  It  must  be  used 
with  precaution,  especially  at  the  outset. 


248 


DISEASES  OF  THE  PHARYNX  AND  LARYNX 


The  results  obtained  by  this  special  treatment  are  not  so 
good  as  those  got  by  varying  the  local  application,  or  even 
by  complete  absence  of  intervention.     The  author  doubts  if 


Fig.   131. — Moritz-Schmidt's  Punch  Forceps. 

any  medicament  is  efficacious  in  an  infection,  so  general 
and  variable  in  its  development  as  tuberculosis.  It  would 
be  better  to  modify  the  receptivity  of  the  soil,  than  pay  too 


Fig.  132. — Gouguenheim's  Laryngeal  Forceps. 

A,  Forceps  cutting  from  behind  forwards  ;  B,  punch  forceps  cutting  from 
before  backwards. 

much  attention  to  the  local  lesion,  and  thus  sacrifice  the 
patient  in  order  to  kill  the  bacillus  ;  whereas  the  primary  aim 
should  be  the  prevention  of  the  reproduction  of  the  latter. 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     249 

M oritz- Schmidt  has  also  recommended  in  the  infiltro- 
œdematous  forms  scarifications  made  with  special  cutting 
forceps.  The  posterior  part  of  the  larynx  and  the  anterior 
portion  of  the  oesophagus  are  grasped  between  the  blades 
of  the  instrument  and  freely  cut.  This  method  has  obtained 
good  results,  but  it  has  not  generally  been  adopted. 

Tracheotomy,  recommended  by  Dr.  Beverley- Robinson, 
does  not  seem  to  be  advisable,  as  the  lungs  are  thereby 
handicapped.  It  should  be  resorted  to  only,  when  asphyxia 
is  imminent. 

Thyrotomy  was  favoured  by  Goris,  as  it  allowed  a 
thorough  curetting  of  the  ulcerated  surface  and  energetic 
cauterization.  This  method  is  nowadays  abandoned,  as  it 
lessens  the  resistive  power  of  the  patient  ;  likewise  extirpation 
of  the  larynx  is  also  to  be  condemned. 

To  sum  up,  in  a  slow  form,  with  limited  ulceration  coin- 
ciding with  a  comparatively  good  state  of  health,  the  author 
advises  a  mild  local  treatment  at  the  outset,  such  as  paint- 
ing with  weak  zinc  chloride  solution  or  carbolized  glycerine 
(i  :  10).  If  the  ulceration  persists  it  should  be  curetted, 
and  carbolized  glycerine  (i  :  3),  or  a  solution  of  lactic  acid, 
applied,  after  anaesthetizing  the  mucous  membrane  with 
adrenalized  cocaine. 

Should  chronic  œdema  exist  in  the  neighbourhood,  local 
ignipuncture  should  be  resorted  to,  or,  if  necessary,  resection 
of  the  mucous  membrane  with  Gouguenheim's  cutting  forceps, 
or  use  tracheotomy  if  stenosis  endangers  life. 

If  the  polypoid  form  is  combined  with  the  ulcerous  form, 
the  polypi  should  be  removed  with  Hering's  curette  or 
Ruault's  cutting  forceps,  after  cocainization  and  adrenaliza- 
tion  of  the  larynx.  The  raw  surfaces  should  be  touched 
with  carbolized  glycerine  or  lactic  acid. 

Solution  to  anaesthetize  the  larynx  : 

li  Hydrochloride    of   adrenalin 

(i  :  1,000)           ...              ...  I  gramme  n\^xv 

Hydrochloride  of  cocaine    ...  i         ,,  gr.  15 

Glycerine  (neutral)               ...  2  grammes  ll^^xxx 

Water  (distilled)  ...              ...  8        „  3ii 


250 


DISEASES  OF  THE  PHARYNX  AND  LARYNX 


In  other  cases  the  galvano-cautery  may  be  preferred,  and 
ignipuncture  apphed  to  the  more  projecting  parts,  and  to  those 
which  cannot  be  removed  by  the  forceps.  Ruault  recommends 
the  prehminary  cocainization  or  adrenahzation  of  the  nasal 
fossae  of  patients  who  are  unable  to  breathe  freely,  reflex 
spasm,  which  sometimes  follows  brushing  of  the  larynx,  being 
thus  avoided. 

When  the  disease  has  reached  the  tertiary  stage,  the  sole 
aim  should  be  to  soothe  the  intolerable  pain  felt  by  the 
patient  by  the  use  of  bromides,  morphia,  cocaine,  adrenalin, 
the  insufflation  of  iodoform,  etc.  The  author  usually  recom- 
mends one  or  other  of  the  following  formulae  : 


]^   Hydrochloride  of  morphia    25  to  60  centi 

grammes. 
Hydrochloride  of  cocaine 


gr.  4  to  9 


50  centigrammes        gr.  7^to 
to  I  gramme  15 


Hydrochloride  of  adrena- 
lin (i  :  1,000) 
Pure  glycerine  ) 

Cherry-laurel  water] 
Water 


2  to  5 

grammes 

ll]^xxx 

to  Ixxv 

àà  50 
400 

)  J 

rsxi 

loxii 
5xiv 

To  be  used  three  or  four  times  daily  for  two  or  three 
minutes.     This  should  not  be  swallowed.     Rinse  the  mouth 


Fig.     133.  — Powder    Insufflator.      (MoRnz  -  Schmidt). 
Glass  canula,  adaptable  to  a  compressed-air  apparatus. 


with  a  little  tepid  boiled  water  before  meals.  Three  or  four 
grammes  of  bromide  of  potassium,  or,  better  still,  of  ben- 
zoate  of  soda,  or  even  antipyrin,  might  be  added  to  the 
above  formula. 

Spraying  should  be  of  short  duration,  so  as  not  to  fatigue 
the    patient,    the    mouth    being   widely   opened,    and    at   a 


I  gramme 

gr-i5 

50  centigrammes 

g^-7h 

15  to  30  grammes 

gr.  2i-to5 

ââ  6  grammes 

àâ  gr.  go 

8  grammes 

5ii 

4 

5i 

2  to  5  centi- 

gr. 3  to  7I 

grammes 

DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     251 

distance   of  15   to   20   centimetres  from   the  apparatus.     If 
necessary,  a  small  gag  should  be  used  to  avoid  fatigue. 

From  time  to  time  a  pinch  of  the  following  powder 
should  be  insufflated  into  the  larynx  : 

B:  Pulverized  menthol 

Hydrochloride  of  cocaine 
Hydrochloride  of  morphia 
Pulverized  iodoform   1 
Pulverized  boric  acid  1 

Or— 

1^    Orthoform 

Pulverized  sugar 
Hydrochloride  of  cocaine 

These  powders  ma}^  be  replaced  by  the  instillation  of  a 
few  drops  of  the  following  solution  : 

1^  Oleate  of  cocaine             ...        5  centigrammes  gi"- 7l 

Hydrochloride  of  adrenalin  15  to  20  minims  lll^xvtoxx 

Guaiacum.          ...              ...  25  centigrammes  n\^iv 

Pulverized  menthol          ...        i  gramme  gr.  15 

Vaseline  oil       ...              ...  15  to  50  grammes  ôiv  to  xii 

Before  taking  food  the  orifice  of  the  larynx  should  be 
painted  with  a  solution  of  cocaine  (i  :  20),  with  or  without 
carbolic  acid  or  adrenalin. 

Before  employing  extreme  doses  of  cocaine  and  morphia, 
the  sensibility  of  each  patient  should  be  tested,  as  in  sensi- 
tive patients  loss  of  appetite  and  tendency  to  lipothymia 
ma}^  occur. 

Generally  speaking,  mild  and  slow  medications,  sometimes 
even  abstention,  are  in  many  cases  the  best  means  of  curing 
laryngeal  tuberculosis. 

Acute  Miliary  Tuberculosis. 

A  true  galloping  phthisis  of  the  larynx,  which  presents  in 
its  course  some  characteristic  features.     It  is  distinguished 


2  52  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

from  ordinary  tuberculosis  by  the  existence  of  bacillary 
lesions  on  the  mucous  membrane,  which  covers  the  pharyn- 
geal cavity,  the  pharynx,  the  base  of  the  tongue,  sometimes 
even  the  mouth  and  lips. 

Etiology. — It  usuall}^  appears  in  tuberculous  patients,  who 
have  reached  the  cachectic  stage,  but  more  rarely  at  the 
outset  of  the  pulmonary  disease.  It  is  observed  in  all  ages, 
more  particularly  between  twenty  and  thirty-five. 

Symptoms. — Fever  usually  begins  with  the  local  affection, 
and  lasts  to  its  conclusion.  It  presents  irregular  exacerba- 
tion, and  it  is  not  rare  to  observe  the  temperature  at  39°  C, 
and  even  reach  40°  C.  or  more. 

The  chief  functional  symptom  is  pain  on  deglutition, 
which  becomes  so  intense,  that  it  prevents  alimentation. 
There  is  no  other  disease  of  the  pharyngeal  cavity,  where 
the  odynphagia  is  so  acute  or  lasting. 

The  lymphatic  glands,  unlike  what  is  observed  in  torpid 
tuberculosis,  may  be  infiltrated,  and  with  pain  radiating  to 
the  ear.  The  larynx  is  painful  to  the  touch  only  in  acute 
crico-arytenoid  arthritis.  On  the  other  hand,  each  move- 
ment of  the  tongue  or  of  the  pharyngeal  cavity  accentuates 
the  pain.  Respiration  is  interfered  with  only,  when  the 
glottic  region  is  inflamed  and  swollen.  The  voice  is  usually 
dull  and  aphonic,  and  respiration  short,  especially  after 
exertion. 

Objective  examination  shows  on  the  posterior  region,  and 
on  almost  the  whole  mucous  membrane,  a  series  of  large 
superficial  ulcers,  the  edges  of  which  are  softened,  infil- 
trated, and  spotted  over  with  yellowish  granulations, 
blending  gradually  into  the  healthy  mucous  membrane. 

Those  lesions  are  disseminated  over  the  whole  surface  of 
the  larynx,  especially  on  the  epiglottis  and  its  folds,  which 
are  swollen  and  muriform. 

The  granulations  very  soon  become  soft,  and  leave  after 
them  cup-shaped  ulcerations,  with  reddish  edges  and  greyish 
base,  which  soon  unite  to  form  large  superficial  purulent  ulcers 
with  irregular  edges.  Those,  often  numerous,  are  separated 
from  each  other  by  pale  and  infiltrated  portions  of  tissue.    The 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     253 

larynx  is  of  a  palish  or  yellowish  hue,  rather  than  red,  as  in 
cancer  and  syphilis.  The  edges  of  the  ulcers  show  the  same 
yellowish  spots,  which  have  characterized  the  outset  of  the 
disease.  Usually  the  infiltration  invades  the  anterior  portion 
of  the  larynx,  specially  the  ventricular  band,  the  vocal  cords, 
and  even  the  subglottic  region.  The  loss  of  substance  of 
the  larynx  is  usually  continuous  with  that  of  the  base  of  the 
tongue  and  the  pharyngeal  cavity.  The  pharyngeal  wall  is 
more  rarely  affected. 

Course — Dttration. — This  form  of  laryngeal  tuberculosis  is 
characterized  by  its  rapid  course.  Apart  from  rare  cases,  in 
which  the  disease  abates  for  some  time,  the  patient,  exhausted 
by  the  pulmonary  lesions,  the  dysphagia,  and  the  pain,  usually 
succumbs  to  general  tuberculosis  and  the  consequent 
cachexia.  This  acute  miliary  form  may  also  occur  at  the 
end  of  ordinary  tuberculosis,  or  after  irritant  treatment. 
The  author  has  even  seen  patients  succumbing  from  vocal 
lesions  prior  to  the  ultimate  stage  of  phthisis. 

Prognosis  of  acute  miliary  tuberculosis  is  evidently  very 
grave.  The  existence  of  fever  is  always  of  bad  omen.  Ac- 
cording to  Ruault,  the  gravest  cases  are  those,  in  which  the 
lungs  are  invaded,  consequent  to  infection  of  the  larynx  and 
the  pharyngeal  cavity. 

Diagnosis  depends  on  the  symptoms  already  referred  to. 
Herpetic  laryngitis  is  also  very  acute  and  very  painful,  but 
it  begins  in  patients  otherwise  in  full  health  and  is  ephemeral. 
The  vesicles  are  less  numerous,  and  are  surrounded  by  a 
red  zone,  without  pronounced  infiltration  of  the  peripheral 
mucosa. 

Treatment  is  similar  to  what  has  been  indicated  for  tuber- 
culosis of  the  pharyngeal  cavity.  Sedative  applications 
suitable  to  assuage  painful  dysphagia  are  advisable,  and 
other  treatment,  such  as  energetic  cauterizations,  curetting, 
etc.,  should  be  avoided. 

Lupus  of  the  Larynx. 

Etiology. — The  primary  cause  of  lupus  of  the  larynx  is  the 
predisposition   of  the   patient.     Hereditary  syphilis  is  also 


254  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

liable  to  favour  the  slow  development  of  tubercle  bacilli. 
Generally  speaking,  it  may  be  admitted  with  Homolle,  that 
lupus  occurs  specially  in  adolescence,  as  frequently  on  the 
mucous  membrane  as  on  the  skin.  Contrary  to  general 
belief,  the  author  thinks,  that  it  is  nothing  exceptional  to 
find  cases  occurring  in  patients  over  fifty. 

Symptoms. — In  some  cases  the  patient  has  a  scrofulous 
appearance,  prominent  cheek-bones,  thick  lips,  glandular  in- 
volvement, sometimes  osseous  lesions,  chilblains,  discharges 
from  the  ear,  keratitis,  etc.  In  patients  affected  with  lupus 
of  the  larynx,  of  the  pharyngeal  cavity,  or  of  the  skin,  the 
nasal  fossae  are  affected  by  a  purulent  pseudo- atrophic 
catarrh,  a  true  prebacillary  catarrh,  from  which  the  germ 
of  infection  may  originate  and  inoculate  the  pharyngeal 
cavity,  epiglottis,  or  vocal  mucosa. 

Functional  disturbances  are  generally  not  very  pronounced, 
and  lupus  of  the  larynx  may  pass  unperceived  for  a  long  time. 
It  is  usually  observed  in  the  course  of  an  aural  affection,  such 
as  otitis  media  acuta,  etc.,  and  of  an  acute  pharyngitis.  At 
other  times  some  patients  complain  of  a  feeling  of  malaise 
rather  than  of  true  pain. 

The  voice  is  altered  only,  when  the  lesions  are  seated  in 
the  larynx  at  the  level  of  the  interarytenoid  region  or  vocal 
cords.  It  then  becomes  husky,  raucous,  even  lost,  some- 
times discordant,  in  consequence  of  the  action  of  the  vocal 
cords  being  interfered  with  by  paresis,  or  by  their  being  partly 
covered  by  the  ventricular  bands. 

Cough  is  not  characteristic.  It  is  even  rare,  being  rather 
a  hemming  and  desire  to  clear  the  throat. 

Respiration  is  interfered  with  only  in  the  hypertrophic 
forms,  the  latter  causing  a  stenosis,  which  is  manifested  by 
stridulous  breathing,  or  even  by  onsets  of  choking,  necessi- 
tating sometimes  opening  of  the  air  tract. 

Deglutition  is  affected  only,  when  there  exist  lesions  in  the 
soft  palate  or  the  pharyngeal  cavity.  It  is  rarely  painful, 
even  in  epiglottic  lupus,  except  at  the  time  of  acute  onsets. 
Moreover,  in  patients  who  have  completely  lost  their  epiglottis, 
the  movement  of  swallowing  is  made  without  difficulty. 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     255 

This  fact  proves,  that  the  rôle  of  the  epiglottis  in  degluti- 
tion is  of  less  importance  than  has  been  usually  supposed  by 
physiologists.  Its  function  seems  not  to  consist  in  covering 
the  glottic  orifice  during  the  passage  of  the  food,  but  rather 
to  direct  liquids  in  the  pharyngo- laryngeal  channel.  The 
base  of  the  tongue  probably  fulfils  the  function  of  protecting 
the  entrance  of  the  air  tract,  as  during  the  first  movement 
of  deglutition  it  depresses  the  glottic  operculum  on  the 
larynx,  or  replaces  the  latter  when  destroyed.  If,  in  the 
case  of  lupoid  patients  without  an  epiglottis,  food  penetrates 
into  the  trachea,  it  is  due  rather  to  diminution  of  laryngeal 
sensibility  and  inertia  of  the  muscles  of  deglutition,  than  to 
the  absence  of  the  epiglottis.  Whenever  deglutition  takes 
place  in  a  normal  and  complete  manner,  none  of  those  dis- 
turbances are  observed. 

On  laryngoscopic  examination  lupus  appears  as  a  reddish 
swelling,  a  true  infiltration  of  the  mucosa,  which  slightly 
precedes  the  ulceration,  or  at  least  the  budding,  of  the  affected 
parts.  When  lupus  is  fully  developed,  there  is  seen  a  series 
of  reddish  mammillary  growths,  having  a  wart-like,  uneven 
appearance,  scattered  over  with  greyish  spots,  the  projection 
and  coloration  of  which  gradually  disappear  at  the  edges  and 
blend  with  the  healthy  mucosa  without  well-defined  demar- 
cation. Those  may  be  supplanted  by  ulcers,  budding  at 
their  bases  and  reaching  to  the  cartilaginous  tissue,  which  is 
liable  in  its  turn  to  be  affected  by  perichondritis,  caries,  and 
necrosis. 

As  a  rule,  lupus  commences  in  the  epiglottis,  which  at 
first  appears  swollen  and  budding,  and  later  on  eroded,  pale, 
rosy  in  places,  yellowish  in  others,  while  here  and  there  the 
fibro-cartilage  is  laid  bare.  On  the  edges  are  seen  small 
irregular  projections,  true  tuberculous  lupoid  products,  hard 
to  the  touch. 

Fairly  often  the  glottic  operculum  is  completely  destroyed, 
and  leaves  in  its  stead  a  surface  rough,  thick,  rosy  or  yellowish. 
The  aryepiglottic  folds  when  affected  are  discoloured,  uneven, 
and  rough,  covered  with  bosses,  giving  them  a  granular 
appearance. 


256  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

It  is  not  rare  to  find  in  the  interarytenoid  region  that 
pseudo-polypoid,  pachydermic  condition  already  referred  to. 

The  ulcers  when  present  are  not,  as  in  ordinary  tuberculosis, 
covered  with  profuse  exudation,  but  have,  on  the  contrary, 
a  slight,  almost  crusty,  yellowish  layer  difficult  to  remove. 
This  loss  of  substance  occupies  either  the  interarytenoid 
region,  where  it  forms  large  rhagades,  or  the  aryepiglottic 
folds,  the  ventricular  bands,  or  the  vocal  cords.  Those 
lesions  always  present  a  granular  reddish  appearance,  as  if 
spread  over  with  small  projections,  greyish  or  yellowish-grey 
in  appearance.  The  vocal  cords  may  be  more  or  less  eaten 
into  by  the  ulceration.  In  that  case  the  organ  is  invaded 
throughout,  and  is  pale,  muriform,  and  more  or  less  deformed. 
Analogous  manifestations  on  the  gums,  the  pharyngeal  cavity, 
lips,  or  skin,  almost  always  accompany  those  pronounced 
forms  of  laryngeal  lupus. 

Pathological  Anatomy.  —  Lupus  of  the  larynx  has  been 
established  histologically,  and  it  is  proved,  that  it  is  a  true 
attenuated  tuberculosis. 

When  treated  with  alcohol,  fixed  in  paraffin  and  coloured 
with  picrocarmine,  lupoid  tissue  presents  superficial  papillary 
projections  visible  to  the  naked  eye. 

Numerous  ridges  and  hollows  surrounded  by  epithelium 
are  observed  on  the  periphery. 

The  epithelium  forms  an  area  more  intense  in  colour  than 
the  remainder  of  the  slide.  It  is  pavemented,  stratified,  and 
composed  of  many  cellular  layers,  and  presents  here  and 
there  true  papillae.  The  whole  has  a  uniform  coloration. 
The  cells  are  very  vacuolar,  and  their  nuclei  are  slightly 
coloured,  or  even  not  at  all.  The  external  pavemented  layers 
are  extremely  thin,  and  visible  only  when  highly  magnified. 
Deeper  down  are  seen  a  great  many  large  polyhedral  cells, 
irregularly  disposed,  constituting  the  body  of  the  epithelium, 
the  deepest  layer  of  which  alone  possesses  cylindrical  cells, 
with  larger  nuclei.  It  is  not  sharply  defined  from  the  subjacent 
tissue. 

The  mucous  tissue  is  constituted  in  some. parts  by 
circular  rosy  zones,  separated  from  each  other  by  connective 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     257 

tissue.  The  zones  themselves  are  formed  of  very  fine  meshes 
of  connective  tissue,  in  the  interior  of  which  are  seen  a  great 
many  necrosed  cells  without  nuclei,  and  some  leucocytes  with 
a  high-coloured  nucleus.  In  the  middle  of  the  necrosed 
tissue  appear  here  and  there  one  or  more  giant  ceils. 

In  other  areas  there  are  no  circular  zones,  the  whole  tissue 
presenting  a  necrosed  appearance,  uniformly  rosy  and  spread 
over  with  some  round  cells.  Finally  certain  spots,  on  the 
contrary,  present  a  considerable  accumulation  of  round  cells. 

The  vessels  are  few,  the  veins  are  dilated  ;  their  walls  are 
very  thin,  tumid,  and  varicose.  The  arteries,  which  are  less 
numerous,  present  lesions  of  endo-  and  periarteritis. 

The  preceding  conclusions  have  been  corroborated  by 
microscopic  examination  of  a  section  of  a  lupoid  epiglottis. 
One  of  the  surfaces  was  intact,  the  other  infected. 

On  the  intact  surface  there  was  no  change  apart  from  a  slight 
congestion  of  the  tissue  and  abundance  of  leucocytes  and 
endo-  and  periarteritis.  The  epithelium  was  normal,  dermo- 
papillar}^  with  sharply-defined  and  high-coloured  nuclei. 

The  epithelium  of  the  affected  surface  was  greatly  thickened, 
but  its  cells  were  of  a  pale,  bluish  colour  ;  most  of  them,  having 
lost  their  nuclei,  were  vacuolar,  and  the  whole  of  the  epithelial 
layer  was  hardly  distinguishable  from  the  subjacent  tissue. 
Leucocytes  were  exceedingly  abundant,  masking  in  many 
places  the  rest  of  the  tissue.  Giant  cells,  round  zones 
of  necrosed  tissue,  surrounded  by  fibrous  rings,  were  easily 
observed. 

On  this  surface  the  perichondrium  of  the  cartilage  had 
disappeared  here  and  there,  and  round  cells  had  made  their 
appearance  in  the  middle  of  the  cartilaginous  surface. 

Bacteriological  examination  rarely  shows  the  presence  of 
bacilli. 

To  sum  up,  the  results  of  bacteriological  examination 
are  : 

(a)  The  epithelium  persists,  although  altered  at  the  surface 
of  the  mucosa. 

(/3)  Within  the  submucous  tissue  necrosed  areas  are 
formed,  surrounded  by  connective  tissue,  v/hich  later  on  will 

17 


258  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

become  thicker  and  isolate  the  points  of  infection  from  one 
another. 

(7)  The  cartilage  is  destroyed  by  the  disappearance  of 
the  perichondrium,  dissociation  of  the  cells,  and  invasion  of 
the  hyaline  substance  by  leucocytes. 

(8)  The  lesion  successively  extends  without  causing  much 
inflammatory  reaction,  as  it  may  leave  intact  a  surface  of  an 
organ  as  thin  as  the  epiglottis,  while  the  reverse  surface  is 
deeply  affected. 

Course  —  Duration.  —  Lupus  in  the  larynx  progresses  by 
successive  onsets.  The  duration  of  the  malady  is  generally 
slow,  except  (which  is  rare)  when  acute  tuberculosis  pre- 
cipitates a  fatal  issue.  Usually  lupus  of  the  larynx,  whether 
isolated  or  accompanied  by  analogous  lesions  in  the  mouth 
or  on  the  skin,  may  endure  for  years,  producing  considerable 
destruction  of  the  throat,  nasal  foss?e,  or  the  nose,  without 
the  lungs  being  implicated.  At  all  events,  the  malady  termi- 
nates either  by  aggravation  of  the  lesions  and  general  tuber- 
culization (a  rather  rare  fact),  or  by  a  temporary  or  definitive 
cure. 

When  the  lesion  is  cured,  the  ulcers  leave  usually  in  their 
stead  cicatricial  synechiee,  which  may  be  seated  between  the 
vocal  cords,  the  aryepiglottic  folds,  or  even  between  the  base 
of  the  tongue  and  the  epiglottis.  Laryngeal  or  pharyngeal 
stenosis,  which  may  necessitate  an  operation,  may  also  be 
a  result  of  lupus.  In  the  most  favourable  cases  cure  takes 
place  before  the  malady  has  made  too  great  ravages,  and 
consequently  without  leaving  subsequent  pronounced  altera- 
tions. 

Diagnosis. — Lupus  of  the  larynx  must  be  diagnosed  and 
distinguished  from  chronic  tuberculous  laryngitis.  In  the 
latter  are  seen  polypoid  vegetations  seated  at  the  level  of  the 
interarytenoid  space,  hyperplastic  erosions,  and  above  all, 
œdematous,  smooth,  even,  jelly-like  infiltration,  without  the 
granular  appearance  of  lupus  Besides,  confusion  of  the  two 
diseases  would  not  be  of  great  importance.  It  is  more  diffi- 
cult to  distinguish  lupus  from  syphilis.  The  existence  of 
lupoid  changes  of  the  pharyngeal  cavity,   and  particularly 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     259 

of  the  skin,  will  be  very  beneficial  for  the  diagnosis.  When 
lupus  is  primary,  it  is  differentiated  from  secondary  syphilis 
by  the  presence  of  roseola.  In  tertiary  syphilis  the  laryngeal 
mucous  membrane  is  red,  congested,  smooth,  and  even,  but 
not  granular,  as  in  lupus.  Syphilitic  ulceration  is  deep, 
crateriform,  purulent,  serpiginous,  sharply  defined  from  the 
surrounding  parts,  and  has  a  greyish  base,  all  of  which 
characteristics  are  non-existent  in  lupus. 

The  course  of  syphilis  is  progressive,  and  develops  in  a  few 
months,  if  not  arrested  by  specific  treatment.  Slowness  of 
evolution,  on  the  contrary,  is  characteristic  of  lupus. 

Leprosy  of  the  larynx  might  perhaps  be  mistaken  for 
lupus,  but  this  lesion  is  exceptionally  rare  in  this  country, 
and  is  accompanied  by  alterations  in  the  skin,  which  preclude 
doubt. 

Till  recently  the  author  was  of  opinion,  that  differential 
diagnosis  of  lupus  and  cancer  was  apparent,  but  he  thinks, 
that  in  some  cases  histological  examination  alone  can  decide 
the  question,  specially  if  it  be  epiglottic  epithelioma  with 
slow  course,  as  observed  in  old  men,  and  at  its  very  outset. 
On  the  other  hand,  cancer  of  the  vocal  cords,  that  has  attained 
to  the  budding  stage,  with  peripheral  infiltration,  is  easily 
differentiated  from  lupus. 

Prognosis  of  laryngeal  lupus  is  usually  benign,  if  the  patient 
is  of  sound  constitution,  and  specially  if  treatment  is  carried 
out  early.  When  intervention  is  too  late,  cicatricial  stenoses, 
which  may  be  accompanied  by  grave  complications,  are 
liable  to  occur.  Unless  the  patient  becomes,  owing  to  over- 
work or  irritant  treatment,  favourable  to  the  development  of 
tuberculous  bacilli,  he  may  be  cured,  as  lupoid  lesions  have 
no  tendency  to  become  general. 

Treatment  must  be  both  general  and  local.  Cod-liver-oil, 
syrup  of  iodide  of  iron,  iodide  of  potassium,  tincture  of  iodine, 
and  even  iodinized  wines,  along  with  a  rigorous  hygienic 
course,  should  be  prescribed.  Locally,  applications  of  caustic 
or  irritant  liquids,  such  as  iodized  or  carbolized  glycerine, 
lactic  acid,  pure  or  in  solution,  should  be  made.  Surgical 
treatment,  such  as  curetting,  scarification,  or  removal  of  the 

17 — 2 


26o 


DISEASES  OF  THE  PHARYNX  AXD  LARYNX 


infected  parts,  should  be  resorted  to  reservedly,  and  often 
in  combination. 

The  galvano-cautery  is  also  an  excellent  means  of  effecting 
a  cure,  and  of  reducing  the  neoplasms  or  the  diffuse  infiltra- 


FiG.  134.  —  Scarifier  with  Con'cealed  Blade. 

tions  which  have  not  been  removed  by  the  curette  or  cutting 
forceps.  Cocainization  and  adrenalization  of  the  vocal 
mucosa  should,  of  course,  be  antecedent.  As  an  additional 
treatment,  an  astringent   spray,  according   to    the    formula 


Fig.   135. — CuTTTXG  Forceps,  with  Krause's  Sliding  Handle. 


given    in    connection    with    laryngeal    tuberculosis,   may    be 
prescribed. 

Saline,  sulphurous,  or  arsenical  waters  are  excellent  means 
of  effecting  definitive  cure.    Once  the  patient  is  apparently 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     261 


cured,  he  should  be 
examined  from  time  to 
time,  specially  in  spring 
and  autumn,  in  order  to 
ascertain  that  no  relapse 
takes  place. 

Leprosy  of  the 
Larynx. 

Leprosy  is  rather  rare 
in  France.  It  is  to  be 
observed  in  the  leper- 
houses  of  Seville,  San 
Remo,  Molde,  Bergen, 
Trondhjem,  and  Reit- 
jerdel. 

Symptoms  vary  accord- 
ing to  the  parts  affected. 
Sensibility  may  be  either 
normal,  diminished,  or 
wanting.  If  the  epi- 
glottis is  affected,  phona- 
tion will  not  be  inter- 
fered with,  whilst  if  the 
lesions  are  situate  on 
the  ventricular  bands, 
the  aryepiglottic  folds, 
and  the  cords  them- 
selves, there  will  be  vocal 
disturbances,  which, 
according  to  Sir  Morell 
Mackenzie,  appear  from 
two  to  eleven  years  after 
the  first  attack.  The 
voice   becomes    raucous 

and  nasal,  owing  to  the  concomitant  lesion  of  the  soft  palate 
and  nasal  fossae.     Then  at  the  last  stage  of  the  malady  it 


Fig.  136. 


-Moure's  Laryngeal 
Curettes. 


202  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

assumes  a  choked  or  absent  timbre.  Respiratory  disturb- 
ances are  also  in  correlation  with  the  degree  of  tumefaction 
in  the  glottic  region,  and  the  intensity  of  inflammatory 
stenosis.  Cough  is  generally  wanting,  because  the  laryngeal 
secretion  is  rather  diminished,  owing  to  the  disappearance 
of  the  glandular  tissue.  As  a  whole,  the  functional  troubles 
are  but  slightly  pronounced,  and  have  nothing  characteristic. 

On  laryngoscopic  examination,  three  different  stages  of 
laryngeal  leprosy  may  be  considered.  The  erythematous 
is  characterized  by  a  simple  chronic  catarrh,  with  pronounced 
vascularization  of  the  vocal  mucosa.  The  infiltrated  stage 
shows  small  papillary  nodules,  very  often  disseminated 
in  the  larynx, .  generally  discrete,  resembling,  according  to 
Virchow,  syphilitic  papules.  Those  morbid  changes  are  so 
closely  allied,  that  the  mucous  membrane  seems  to  be  infil- 
trated and  thickened.  They  have  sometimes  a  yellowish 
hue,  a  little  paler  than  the  healthier  parts  of  the  mucosa. 
Zones  of  anaesthesia  are  always  present  at  their  level,  or 
surrounding  them.  At  other  times  inflammatory  swelling 
and  infiltration  predominate,  while  the  tubercles  are  rather 
rare  and  difficult  to  perceive.  At  this  stage  some  muscular 
paresis  is  sometimes  observed,  which  interferes  with  phona- 
tion and  respiration.  During  the  course  of  this  hypertrophic 
phase  leprous  masses  may  resemble  small  excrescences, 
occupying  the  aryepiglottic  folds  or  the  whole  epiglottis, 
which  then  assumes  the  well-known  prickly  appearance  (like 
the  husk  of  a  horse-chestnut). 

The  tertiary  period  is  characterized  by  ulceration  and 
necrosis  (Gibb,  Sir  Morell  Mackenzie),  caused  by  the  liquefac- 
tion of  the  secondary  nodules.  There  may  be  loss  of  sub- 
stance in  the  cartilage,  and  the  glottic  operculum  may  totally 
disappear.  Adherence  between  the  different  portions  of  the 
larynx  and  the  base  of  the  tongue  and  onsets  of  acute 
oedema  may  be  observed.  As  a  rule,  the  patient  rapidly 
succumbs  to  the  progress  of  asphyxia,  if  surgical  interference 
fails  to  dispel  respiratory  difficulties.  Usually  manifestations 
of  leprosy  are  to  be  found  on  the  uvula,  the  soft  palate,  and 
often  even  in  the  pharynx  and  nasal  fossae. 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     263 

Pathological  Anatomy, — Lepros}^  of  the  larynx  is  similar  to 
that  of  any  other  organ.  According  to  Virchow,  the  nodule 
contains  numerous  cells  of  connective  tissue,  closely  united, 
with  free  nuclei  intervening.  Nuclei  and  cells  appear  to  be 
grouped  around  bloodvessels  and  glands.  Generally  the 
epithelium  is  healthy,  except  in  the  ulcerated  parts,  and  the 
cartilage  is  almost  always  normal.  As  Masini  and  Thin  have 
demonstrated,  the  characteristic  feature  of  the  lesion  is  the 
presence  of  round  cells  analogous  to  blood-corpuscles,  which 
contain  one  or  several  bacilli  of  leprosy.  The  glandular 
tissue  almost  always  disappears. 

Course,  Duration,  Termination. — The  course  of  leprosy  is 
generally  slow.  It  may  endure  for  years,  before  it  reaches 
the  tertiary  period,  but  it  is  seldom  possible  to  impede  it, 
even  with  the  best  treatment. 

Prognosis  is  always  grave,  but  if  the  affection  remains  con- 
fined to  the  point  of  origin,  it  may  not  endanger  the  life  of 
the  patient — at  least,  for  several  years.  When  leprosy  has 
attained  to  the  stage  of  tumefaction  and  ulceration,  the 
prognosis  is  fatal. 

Diagnosis  is  generally  facilitated  by  cutaneous  manifesta- 
tions precedent  to  the  leprosy.  Virchow,  however,  thinks, 
that  a  certain  resemblance  may  exist  between  leprosy  and 
syphilis  or  lupus  of  the  larynx.  In  that  case  histological 
examination  will  confirm  the  diagnosis. 

Treatment  is  usually  difficult  to  apply,  and  is  often  useless. 
The  best  means  consist  of  hygienic  and  prophylactic  precau- 
tions. The  patient  should  be  isolated  to  avoid  contagion. 
Locally,  painting  with  lactic  acid,  spraying,  and  curetting  of 
the  larynx  might  be  used,  with  the  internal  medication 
usually  prescribed  for  the  disease.  Most  frequently  the 
complications  alone  are  treated,  and  tracheotomy  practised 
when  asphyxia  is  imminent. 

Neuro-muscular  Affections  of  the  Larynx, 

There  are  two  chief  classes  of  nervous  affections  of  the 
larynx — namely  (i)  neurosis  of  sensibility,  and  (2)  neurosis 
of  motility. 


204  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

The  first  group  comprises  anaesthesia,  hypersesthesia, 
parsesthesia,  and  neuralgia  ;  the  second^  paresis,  paralysis, 
and  spasms. 

Disturbances  of  Sensibility. 

Anaesthesia. — This  functional  trouble  is  mostly  ob- 
served in  hysteria.  It  appears  in  the  form  of  zones  of 
insensibility  in  the  larynx  and  trachea.  Chairou  and  Thaon 
have  demonstrated,  that  neuropathic  anaesthesia  is  very 
common  in  the  epiglottis,  and  not  rare  in  the  rest  of  the 
vocal  mucosa.  In  typical  cases  the  walls  of  the  larynx,  the 
pharyngeal  cavity,  and  the  soft  palate,  may  be  titillated 
without  the  least  reflex.  This  loss  of  sensibility  is  equally 
met  with  in  emotional  patients.  Anaesthesia  usually  accom- 
panies profound  narcosis,  and  is  also  observed  in  patients 
affected  with  recurrent  compression.  However,  the  mucous 
membrane  generally  retains  its  normal  sensibility,  unless  the 
superior  laryngeal  nerve  is  involved. 

In  some  grave  diseases  (cholera,  diphtheria,  etc.)  loss  or 
perceptible  diminution  of  sensibility  is  also  observed.  Anaes- 
thesia of  the  vocal  mucosa  is  not  rare  in  central  affections, 
especially  in  bulbar  lesions  and  general  paralysis.  In  de- 
mentia this  is  the  cause  of  the  penetration  of  a  bolus  or  of  a 
foreign  body  into  the  air  passages  during  deglutition.  It 
frequently  exists  among  epileptics  during  the  crisis,  and  for 
some  time  after.  Hemianaesthesia  is  also  observed  during 
laryngeal  hemiplegia  of  central  origin. 

Symptoms  are  very  often  but  slightly  pronounced.  In  the 
central  forms  dysphagia  exists,  owing  to  the  loss  of  motor 
sensibility  of  the  constrictor  muscles  of  the  pharynx.  Semi- 
solid food  usually  enters  the  air  tract,  and  causes  violent  and 
painful  spasms  of  cough.  It  is  probable,  that  the  penetration 
of  alimentary  substances  into  the  trachea  is  rather  the  conse- 
quence of  concomitant  paralysis  of  the  depressor  muscles  of 
the  epiglottis,  or  of  an  incomplete  movement  in  deglutition, 
than  of  the  ansesthesia  of  the  superior  region  of  the  laryngeal 
vestibule. 

The  patient  usually  complains  of  the  sensation  of  a  foreign 
body  in  the  throat. 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     265 

The  anaesthetized  parts  play  the  rôle  of  a  true  foreign 
body  towards  the  neighbouring  portions,  that  retain  their 
sensibility. 

Thus  is  explained  the  sensation  of  the  feeling  of  a  ball  in 
the  throat,  or  the  constriction  experienced  by  some  hysterical 
people  with  an  insensible  laryngeal  mucosa.  Anaesthesia 
is  bilateral,  rarely  unilateral.  The  seat  of  the  anaesthesia 
and  its  intensity  is  determined  by  the  use  of  the  probe. 
The  patient  almost  always  perceives  the  sensation  of  hot 
and  cold,  unless  a  profound  nervous  disturbance  has 
occurred.  The  sensibility  of  the  organ  may  be  roughly 
determined  by  titillating  the  vestibule  of  the  larynx  with 
the  finger.  Laryngoscopic  examination  reveals  no  apparent 
lesion. 

Course,  Duration,  Termination. — The  course  and  duration 
are  variable,  and  depend  on  the  cause  of  the  disease. 
Anaesthesia  of  bulbar  origin  is  usually  progressive,  and 
prognosis  is  grave.  If  it  is  consequent  to  diphtheria,  it 
disappears  along  with  the  other  symptoms  of  intoxication. 
Anaesthesia  in  the  tertiary  period  of  tuberculosis,  arising 
from  compression  or  degeneration  of  the  laryngeal  nerves, 
and  is  incurable  unless  the  compression  and  degeneration  have 
been  of  short  duration.  In  hysteria  anaesthesia  may  change 
its  seat,  and  attack  other  parts  of  the  larynx  or  of  the  body. 
The  course  is  in  such  cases  very  variable,  as  in  all  other 
disturbances  caused  by  this  neurosis. 

Diagnosis. — Certain  lesions  of  the  nerve  centres  begin 
with  analgesia  or  even  total  loss  of  sensibility  of  the  laryngeal 
mucosa.  Whenever  food  tends  to  penetrate  into  the  air 
tract,  the  patient  should  be  put  under  surveillance,  unless  that 
symptom  is  obviously  due  to  peripheral  causes. 

The  previous  history  of  the  patient  should  be  of  importance 
in  recognizing  the  nature  of  the  nervous  disturbances. 

In  case  of  need,  an  electric  current  introduced  into  the 
larynx  will  furnish  precise  ideas  of  the  nature  and  intensity 
of  the  anaesthesia. 

Prognosis  varies  according  to  the  cause  of  the  disease. 
Danger   lies  in   the    possible    penetration    of   a    bolus    into 


266  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

the  air  tract.  In  bulbar  or  cerebral  lesions  prognosis  is 
always  grave.  Alimentation  may  become  absolutely  im- 
possible, and  constant  employment  of  the  oesophageal  tube 
be  necessary. 

Treatment  should  bear  first  on  the  general  causes  of 
perturbation.  In  cases  of  diphtheria  recourse  should  be  had 
to  tonics  and  to  electricity  applied  as  Faradic  currents,  one 
pole  being  placed  at  the  nape  of  the  neck,  the  other  on  the 
external  region  of  the  larynx,  or  even  in  the  lar3'nx.  Massei 
and  Sir  Morell  Mackenzie  have  successfully  used  continuous 
currents,  the  two  poles  being  applied  on  the  vocal  mucosa. 
In  such  cases  the  electrodes  should  not  remain  long  on 
the  same  place,  in  order  to  avoid  the  formation  of  scars. 
The  current  must  be  sufficiently  strong  to  produce  a  dis- 
agreeable sensation,  but  not  pain.  In  hysteria  electricity 
in  all  its  forms  is  beneficial. 

Strychnine  in  doses  of  5  to  6  or  even  8  milligrammes  a 
day,  according  to  the  strength  of  the  patient,  successfully 
counteracts  neuropathic  anaesthesia. 

In  grave  cases  of  central  origin,  accompanied  by  difficulty 
of  deglutition,  the  patient  should  be  fed  with  the  oesophageal 
tube. 

Hyperaesthesia. — As  sensibility  of  the  vocal  mucosa 
varies  in  different  subjects,  it  is  difficult  to  assign  precise 
limits  to  hyperaesthesia  of  the  larynx.  This  disease  is  very 
pronounced  in  patients  affected  with  pulmonary  tuberculosis, 
even  when  the  vocal  mucosa  shows  no  change.  In  some 
grave  inflammations  of  the  epiglottis,  ar^-epiglottic  folds, 
or  interarytenoid  region  it  may  also  be  observed.  Hyper- 
aesthesia is  sometimes  combined  with  parassthesia  or  neuralgia 
in  hysteria,  and  is  common  at  the  time  of  dentition,  menstrua- 
tion, or  pregnancy. 

Symptoms. — -Hyperaesthesia  of  the  larynx  may  be  localized 
or  diffuse.  In  the  first  case  the  patient  has  a  pricking 
sensation,  which  abates  on  deglutition  and  reappears  some 
hours  afterwards.  In  diffuse  hyperaesthesia  the  patient 
feels  at  the  orifice  of  the  air  tract  a  sensation  of  burning, 
constriction,  or  tearing.     Some  are  afiected  with  phonophobia. 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX    267 

refuse  to  speak,  and  have  an  inclination  to  clear  the  throat 
continuously.  On  direct  examination,  the  mucosa  appears 
quite  normal. 

Prognosis. — The  affection  is  most  frequently  obstinate  and 
liable  to  recur.  The  patient  often  exaggerates  its  gravity, 
yet  the  prognosis  is  on  the  whole  benign,  except  when  the 
hypersesthesia  ushers  in  tuberculosis. 

Treatment. — When  hypersesthesia  is  consequent  on  any 
inflammation  of  the  laryngeal  mucosa,  the  treatment  consists 
in  counteracting  that  irritation.  When,  on  the  other  hand, 
the  larynx  is  healthy,  the  treatment  should  bear  on  the 
general  condition  of  the  patient,  and  consist  of  a  sedative 
course  of  waters  (baths,  douches,  etc.). 

The  various  bromide  salts,  antipyrin,  and  valerian,  internally 
administered,  have  given  good  results. 

Cocainized  solutions  are  indicated  locally.  Cold,  internally 
and  externally,  or  moist  heat,  under  the  form  of  compresses 
often  renewed,  are  excellent  remedies.  Treatment  must, 
of  course,  vary  according  to  the  patient,  and  the  torm  and 
intensity  of  the  hypersesthesia. 

Neuralgia. — Laryngeal  Hyperaesthesia  sometimes 
appears  as  limited  painful  areas  occurring  in  crises,  and 
may  be  regarded  as  a  true  neuralgia.  This  variety  of 
neurosis  is  considered  rare  in  the  larynx.  According  to 
Ruault,  it  is  more  frequent  in  women  than  in  men,  and 
occurs  specially  in  neuro-arthritic  subjects.  Lennox  Browne, 
on  the  contrary,  attributes  it  to  ansemia  and  incipient  tuber- 
culosis. Neuralgia  occurs  as  a  reflex  symptom  in  the  naso- 
pharynx, or  pharynx. 

Symptoms. — Laryngeal  neuralgia  is  manifested  by  a  series 
of  shooting  pains  occurring  in  onsets,  usually  localized  at 
the  level  of  the  great  cornu  of  the  hyoid  bone,  thence  radiat- 
ing towards  the  ear  or  the  inferior  part  of  the  air  passage. 
Speaking  or  any  exertion  of  the  larynx  is  sufficient  to 
determine  its  appearance. 

Diagnosis. — Laryngeal  neuralgia  must  be  distinguished 
from  neuralgia  of  dental  origin,  from  otalgia,  and  all  inflam- 
matory affections  of  the  pharyngeal  cavity  and  the  base  of 


268  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

the  tongue.  The  nasal  fossae  should  also  be  examined,  as 
their  irritation  may  be  the  cause  of  laryngeal  neuralgia. 

Treatment  is  almost  identical  with  that  of  hyperassthesia, 
and  should  consist  of  antipyrin,  phenacetin,  quinine,  even 
aconite.  Cold  itself,  or  combined  with  methyl- chloride, 
or  preferably  warm  compresses,  are  of  assistance  to  subdue 
the  pain. 

Paraesthesia  may  originate  chiefly  in  hysteria.  It  is 
also  met  with  in  hypochondriacs,  neurasthenic  or  syphilo- 
phobic  subjects. 

According  to  Lennox  Browne  and  Gottstein,  this  symptom 
ushers  in  tuberculosis. 

It  is  also  observed  in  patients  who  have  had  foreign  bodies 
in  their  throat,  or  have  used  their  voice  immoderately. 

In  naso-pharyngeal  lesions  it  is  not  rare,  and,  according 
to  Paul  Koch,  its  existence  may  be  observed  in  patients 
affected  with  minute  laryngeal  tumours. 

Symptoms.  —  The  patient  imagines  the  presence  of  a 
foreign  body  {e.g.,  fish-bone)  in  the  larynx.  Sometimes  he 
experiences  the  sensation  of  a  strong  constriction  of  the 
throat. 

Paraesthesia  is  differentiated  from  neuralgia  by  the  fact, 
that  it  disappears  during  deglutition  and  even  for  an  hour 
or  two  after  meals,  and  then  reappears  as  intense  as  before. 
Laryngoscopic  examination  is  negative,  the  mucous  mem- 
brane appearing  quite  normal. 

Course,  Duration,  Progress.  —  Paraesthesia  is  more  tena- 
cious than  the  other  preceding  forms  of  neurosis.  It  is 
frequently  combined  with  anaesthesia,  and  its  duration 
depends  on  the  nature  of  the  disease,  of  which  it  is  a 
manifestation. 

Diagnosis. — This  affection  cannot  be  confused  with  the 
pain  occasioned  by  the  presence  of  a  foreign  body  in  the 
larynx,  for  not  only  laryngoscopic  examination,  but  a  whole 
series  of  manifestations  preclude  all  doubt. 

It  must,  above  all,  be  ascertained,  whether  there  exist 
general  causes — tuberculosis,  anaemia,  hysteria — or  chronic 
local  lesions  of  the  base  of  the  tongue,  the  pharynx,  and 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     269 

the    nasal    fossae,    which    might    explain    the    existence    of 
paraesthesia. 

In  neurasthenic  people,  who  believe  that  they  are  affected 
with  tuberculosis,  cancer,  syphilis,  the  very  existence  of 
parassthesia  is  of  assistance  to  determine  the  diagnosis  of 
general  neurosis. 

Prognosis  varies  according  to  the  causes  of  the  affection. 
It  is  usually  benign,  and  the  malady  rarely  resists  a  well- 
directed  general  and  local  treatment.  However,  it  is  very  apt 
to  recur  under  the  influence  of  the  least  emotion,  or  of  the 
causes  which  determined  its  first  appearance. 

Treatment  must  bear  first  of  all  on  the  general  condition  of 
the  patient,  and  varies  according  as  paraesthesia  is  accom- 
panied with  diminution  or  exaggeration  of  laryngeal  sensi- 
bilit}^  In  the  former  case,  general  tonics — e.g.,  arsenic, 
kola,  strychnine,  valerian,  physical  exercise — should  be  pre- 
scribed.    In  the  latter  form,  bromides  are  preferable. 

Hydrotherapy  (cold  or  lukewarm  douches)  is  beneficial  in 
both  forms  of  paraesthesia. 

In  the  application  of  local  topics,  hyperaesthesic  and 
ansesthesic  forms  must  be  carefully  distinguished.  In  the 
former  case,  preparations  with  a  cocaine  base  may  be  em- 
ployed as  a  spray,  gargle,  paint,  or  wash.  The  author 
recommends  the  following  formula  : 

I^c    Hydrochloride  of  cocaine 

Tincture  of  opium  (Sydenham's) 

Bromide  of  potassium 

Glycerine  (pure) 
To  be  used  for  painting  the  posterior  part  of  the  throat  or 
the  orifice  of  the  larynx. 

In  the  latter  case,  cauterization  of  a  small  part  of  the 
pharynx  with  crystallized  chromic  acid,  or  better  still,  with 
the  galvano-cautery,  is  more  suitable  in  paraesthesia  with 
anaesthesia  ;  mentholated  solutions  (i  :  30  or  i  :  50)  are  also 
useful. 

Electricity,  in  whatever  form,  is  applicable  to  both  kinds  of 


25  to  50  centi- 

gr. 

,4  to  8 

grammes 

I  gramme 

l\xv 

2  grammes 

gr-30 

30 

ôvii 

270  DISEASES  OF  THE  PHARYXX  AXD  LARYNX 

parassthesia.  Regular  physical  exercise  (but  not  to  excess) 
and  travelling  are  also  of  value.  Cure  may  be  obtained  in 
many  cases  by  suggestion. 


Disorders  of  Motility. 

Before  attempting  the  study  of  muscular  paralysis  of  the 
larynx,  it  is  advisable  to  say  a  few  words  on  the  anatomy  and 
physiology  of  the  laryngeal  muscles.  Thev  may  be  classified 
into  two  main  groups — adductors  and  abductors. 

The  first  group  comprises  all  the  muscles  of  the  larynx, 
with  the  exception  of  the  posterior  crico-arytgenoidei,  which 
are  the  only  abductors. 

These  various  muscles  are  innervated  by  :  (i)  The  superior 
laryngeal  nerves,  which  divide  in  two  branches — the  one 
internal  and  sensory,  the  other  external  and  motor — in- 
nervating the  crico-thyroid.  (2)  The  inferior  laryngeal  (right 
and  left  recurrent),  two  in  number,  one  on  each  side. 
That  on  the  right,  originating  in  the  pneumogastric,  winds 
round  and  under  the  subclavian,  and  ascends  along  the 
trachea,  distributing  itself  among  the  muscles  on  the  right 
side  of  the  larynx,  the  crico-thyroid  being  excepted.  That 
on  the  left  is  somewhat  longer  than  the  foregoing,  and 
passes  under  the  aortic  arch,  around  which  it  coils,  and 
subsequently  proceeds  between  the  oesophagus  and  the 
trachea.  It  innervates  the  muscles  of  the  left  side.  The 
difference  of  the  course  of  those  two  nerves  explains  the 
diversity  of  the  pathogenic  lesions  of  paralysis  of  the  right 
and  the  left.  ('3)  A  third  nerve,  the  spinal  accessory,  con- 
tributes to  the  innervation  of  the  larynx,  as  the  internal 
branch  of  this  nerve,  after  leaving  the  skull,  anastomoses 
with  the  pneumogastric,  which  itself  furnishes  the  superior  and 
inferior  lar^-ngeal  nerves.  This  branch  of  the  spinal  accessory 
has  for  some  time  past  been  regarded  as  the  nerve  of  phona- 
tion, because  when  it  was  torn  at  its  point  of  origin,  aphonia 
ensued.  Other  physiologists  think,  that  it  is  impossible  to 
cut  this  nerve  without  injuring  the  pneumogastric  at  the 
same  time.     This  classification  of  the  laryngeal  nerves  has 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     271 

long  been  a  subject  of  discussion,  and  it  is  nowadays 
admitted,  since  the  discoveries  of  Exner,  and  chiefly  of 
Onodi,  that  there  exists  anastomosis  between  the  fibres  of 
the  recurrent  and  those  of  the  superior  lar5'ngeal,  which 
might  explain,  how  the  inferior  laryngeal  contain  sensitive 
fibres,  borrowed  from  the  superior  laryngeal. 

The  motor  disturbances  of  the  larynx  may  be  divided  into 
several  chief  groups,  which  must  be  described  separately  : 
(i)   paralysis  from    central  causes  ;    (2)  paralysis  dependent 


Fig.   137. — Transverse  Section  of  the  Neck  at  the  Level  of  the 
First  Dorsal.     (After  Ziemssen  and  Braune.) 

I,  Wall  of  the  trachea;  2  and  2',  thyroid  body;  3  and  3',  right  and  left 
récurrents;  4,  œsophagus  ;  5,  vertebral  body;  6,  apex  of  the  right 
lung. 

on  a  lesion  of  the  vago-spinal  branches^aryngeal  superior 
and  inferior  ;  (3)  paralysis  localized  in  a  single  muscle  of  the 
larynx  ;  and  (4)  spasms  of  the  laryngeal  muscles. 


A.    PARALYSIS    OF    CENTRAL    ORIGIN. 

The  central  lesions,  w^hich  may  cause  laryngeal  paralysis, 
are  very  numerous.  They  are  diffuse  sclerosis,  progressive 
bulbar  paralysis,  tabes,  syphilis  at  the  tertiary  period  (cere- 


272  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

bral  gumma),  syringomyelia,  and  sclerosis  en  plaques,  to 
which  Sir  Morell  Mackenzie  adds  a  certain  number  of 
intoxications  (saturnism,  etc.).  Although  Gibb  considers 
unilateral  paralysis  as  fairly  frequent  in  patients  affected 
with  hemiplegia  caused  by  recent  apoplexy,  the  author's 
experience  does  not  confirm  that  theory. 

Symptoms. — The  s3'mptoms  of  laryngeal  paralysis  of  central 
origin  are  not  characteristic,  the  general  disturbances  being 
the  more  prominent.  The  modification  in  the  motility  of  the 
muscles  varies  according  to  the  extent  of  the  bulbar  lesion. 
The  paralysis  may  be  double  and  complete,  or,  on  the  con- 
trary, unilateral.  Usually  the  paresied  vocal  cords  lie  in  the 
middle  line,  as  has  been  noted  by  Semon  and  others. 

Along  with  Lannois,  the  author  admits,  that  vocal  disturb- 
ances are  most  frequent  in  labio-glosso-laryngeal  paralysis. 
Charcot  has  described  a  defect  of  adduction  of  the  cords, 
which  explained  their  aphony.  Laryngoscopic  examination 
alone  determines  the  nature  of  the  lesion,  which  produces 
the  vocal  disturbances.  Here  it  is  a  comparatively  trivial 
symptom,  but  otherwise  in  the  case,  where  the  two  vocal 
cords  are  fi^xed  in  the  mesial  line,  direct  examination  permits 
of  therapeutic  deductions  being  drawn. 

Pathological  Anatomy. — The  lesions  observed  on  autopsy 
are  very  variable,  depending  on  the  cause  of  paralysis.  In  a 
case  recorded  by  Sir  Morell  Mackenzie  there  was  degenera- 
tion of  the  medulla  oblongata,  which  appeared  soft  and  grey. 
In  another  recorded  by  Penzold,  the  olivary  bodies  were 
badly  defined,  and  the  anterior  pyramids  had  a  grey,  gela- 
tinous appearance.  Cruveilhier  has  seen  grey  degeneration 
of  the  posterior  cords  and  of  the  restiform  bodies,  h  con- 
siderable attenuation  of  the  pneumogastric  branches  (spinal 
and  recurrent)  at  their  origin,  a  focus  of  softening  in  the  left 
restiform  body,  and  a  grey  degeneration  of  the  posterior 
cords,  have  also  been  noted.  In  one  case  described  by 
Luys  there  were  discovered  on  the  protuberance,  on  each  side 
of  the  mesial  line,  minute  areolar  foci,  containing  a  serous 
fluid,  this  lesion  being  accompanied  by  secondary  degenera- 
tion of  the  recurrent  nerves  and  of  the  laryngeal  muscles. 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     273 

Seguin,  on  the  contrary,  observed  on  the  third  right  frontal 
convolution  a  yellow  elastic  patch,  affecting  only  the  grey 
substance,  and  founds  on  that  autopsy  the  existence  of  a 
cortical  laryngeal  centre  at  this  level.  The  question  has 
been  debated  by  Krause,  Massini,  and  more  recently  by 
Semon  and  Horsley,  and  others,  but  as  yet  the  existence  of 
a  centre  has  not  been  definitely  established. 

Diagnosis  is  based  more  on  the  examination  of  the  patient, 
the  manner  in  which  the  paralysis  has  taken  place,  and  on 
the  accompanying  symptoms,  rather  than  on  laryngoscopic 
examination.  The  mirror  only  reveals  whether  the  cords 
are  in  the  middle  line  (paralysis  of  the  posticus,  with  con- 
traction of  its  opponent),  in  the  cadaveric  position,  or  in 
forced  abduction,  the  last  being  very  rare. 

Course  —  Prognosis. — Both  vary  according  to  the  cause 
of  the  paralysis.  The  paralyzed  vocal  cord  may  entirely 
recover  if  the  paralysis  is  due  to  cerebral  haemorrhage  ;  yet, 
even  in  the  most  favourable  cases  the  voice  rarely  resumes 
its  normal  timbre.  When  paralysis  is  bilateral,  an  ameliora- 
tion, which  is  more  apparent  than  real,  is  often  seen.  Indeed, 
in  cases  where  paralysis  of  the  dilators,  with  contraction  of 
the  adductors,  causes  respiratory  disturbance,  the  cords  may 
be  seen  to  travel  from  the  middle  line,  and  assume  an  almost 
cadaveric  position.  Respiration  then  becomes  easier,  not 
because  the  malady  has  retroceded,  but  because,  the  muscular 
atrophy  having  progressed,  the  contraction  of  the  adductor 
muscles  of  the  vocal  cords  has  gradually  disappeared,  and 
with  it  the  respiratory  disturbance. 

Treatment  will  be  that  of  the  dominant  lesion — the  cause 
of  the  laryngeal  affection. 

B.    PARALYSIS    OF    PERIPHERAL    ORIGIN. 

I.  Vago-spinal  Paralysis.  —  Etiology.  —  Owing  to  the 
length  of  the  tract  traversed  by  the  pneumogastric,  and  to 
its  particular  position  in  the  neck,  it  is  easy  to  under- 
stand how  it  may  very  often  be  affected.  It  is  sometimes 
implicated  in  lesions  of  the  neighbouring  parts — e.g.,  the 
large   bloodvessels   (the    subclavian    on    the    right,   and    the 

18 


274 


DISEASES  OF  THE  PHARYNX  AND  LARYNX 


aorta  on  the  left),  the  œsophagus,  the  trachea,  the  thyroid 
gland,  and  the  lymphatics.  Thus  certain  aneurisms,  malig- 
nant degenerations,  glandular  h3'pertrophies,  are  apt  to  press 


Fig.  138. — Relation'  of  the  Pxeumogastric  and  Laryngeal  Nerves. 
(After  Ziemssen  and  Henle.) 

,  ^Mastoid  apophysis;  2,  jugular  vein;  3,  ganglionic  plexus  of  the  pneumo- 
gastric  ;  4,  internal  branch  of  the  spinal;  5,  pharyngeal  branch  of  the 
pneumogastric  anastomosing  with  the  pharyngeal  branch  of  the  glosso- 
pharyngeal ;  6,  superior  laryngeal  nerve  ;  7  and  S,  internal  and  external 
branches  of  the  superior  laryngeal  ;  9,  left  pneumogastric  ;  10,  thyro- 
hyoid muscle;  11,  cardiac  branch  of  the  pneumogastric;  12,  right 
pneumogastric;  13.  right  cardiac  branches;  14  and  15,  right  and  left 
récurrents  ;   16,  course  of  the  vein. 


on  the  vagus.     The  tissue  of  the  nerve  may  be  injured  by 
incidental  wounds,  or  during  operations  in  the  neck. 

Symptoms. — The   symptoms  accompanying   lesions  of  the 
pneumogastric  are   of  two   kinds  :  (i)  cardiac  disturbances^ 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     275 

which  usually  rapidly  disappear  from  the  compensatory 
action  of  other  nerves  ;  (2)  vocal  modifications  (aphonia  or 
hoarseness).  Those  disturbances  are  variable,  according  as 
the  lesion  bears  on  one  or  both  nerves,  and  as  they  are  partly 
or  totally  affected. 

On  laryngoscopic  investigation,  the  vocal  cord  appears  as 
in  recurrent  lesions.  However,  the  pneumogastric  being  a 
mixed  nerve,  its  compression  determines  immobilization  of 
the  two  cords  almost  in  the  middle  line,  the  one  being 
paralyzed,  and  the  other  in  reflex  contraction.  Consequently 
vocal  disturbance  may  be  slightly  pronounced,  whereas 
respiration  may  be  considerably  interfered  with,  and  suffo- 
cation and  even  asphyxia  take  place  if  tracheotomy  is  not 
performed. 

Respiration  is  stridulous  and  loud  during  both  inspiration 
and  expiration.  The  noise  made  by  the  patient  during  his 
sleep  is,  as  it  were,  characteristic  of  this  form  of  dyspnoea, 
and  the  more  so  if  he  is  the  subject  of  tracheal  stenosis.  The 
free  edge  of  the  vocal  cords  being  relaxed,  and  almost  in 
juxtaposition,  produces  at  ingress  or  egress  of  air  charac- 
teristic sonorous  vibrations. 

2.  Paralysis  of  the  Superior  Laryngeal  Nerve, — 
The  superior  laryngeal  nerve  is  a  sensory  nerve  through  its 
internal,  and  a  motor  nerve  through  its  external  branch, 
although  Ttirck  has  pointed  out  a  case  of  crico-thyroid 
atrophy  without  concomitant  lesion  of  the  superior  laryngeal. 

Etiology. — Paralysis  of  the  superior  laryngeal  is  observed 
as  a  consequence  of  somewhat  intense,  acute  catarrhal 
laryngitis,  or  of  intoxications  such  as  diphtheria.  It  is  also 
seen  in  hysteria.  Lastly,  every  lesion  affecting  the  nerve 
filament  at  the  point  of  its  entering  the  larynx  may  cause 
paralysis. 

Symptoms. — Two  kinds  of  symptoms  are  noted  :  (i)  anaes- 
thesia ;  (2)  paretic  disturbances.  The  former  is  demonstrated 
by  a  very  careful  examination  of  the  larynx,  with  the  aid  of 
the  probe. 

The  loss  of  sensibility  of  the  larynx  is  usually  accompanied 
with  hyposesthesia,  and  often  even  with  anaesthesia,  of  the 

18—2 


276  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

phar3mgeal  cavity.  The  patient  then  complains  of  feehng  a 
ball  in  the  throat.  Sir  Morell  Mackenzie  records  disturb- 
ances of  deglutition. 

When  one  or  two  superior  lar3^ngeal  nerves  are  paralyzed, 
or  in  a  state  of  paresis,  vocal  disturbances,  due  to  lack  of 
function  of  the  crico-thyroid  muscles,  are  observed.  The 
voice  is  broken.  Some  sounds  cannot  even  be  emitted. 
During  inspiration  the  vocal  cords  are  lax,  intermittent 
valvular  sounds  being  heard. 

On  lar3'ngoscopic  examination,  the  vocal  mucosa  appears 
absolutely  normal  ;  but  if  the  patient  utters  the  vowel  e,  the 
vocal  cords  are  not  pearh%  as  usual,  but  i^abby  and  soft, 
forming  a  somewhat  characteristic  undulated  line.  During 
strong  inspiration  the  vocal  cords  form  an  isosceles  triangle 
\vith  sinuous  sides.  The  absence  of  parallelism  and  approach 
of  the  thyro-arytenoidean  folds  ma}^  be  considered  char- 
acteristic. It  is  possible  to  elevate  the  thyroid  cartilage,  and 
render  the  cords  sufficiently  tense  to  give  the  voice  a  normal 
timbre. 

The  course  of  those  disturbances  depends  on  their  causation, 
and  is  quite  different,  in  a  central  affection,  from  that  occa- 
sioned by  paralysis  à  fvigore  or  hysterical. 

Prognosis. — Those  paralyses  are  not  in  themselves  grave,  as 
they  do  not  compromise  the  life  of  the  patient.  Yet  vocal 
disturbances  may  be  important  in  the  case  of  professionals. 
As  the  orifice  of  the  air  tract  is  in  a  state  of  anœsthesia,  the 
food  is  liable  to  enter  the  larynx,  and  bring  about  secondary 
pneumonia  or  rapid  death.  These  disturbances,  happening 
specially  after  diphtheria,  may  necessitate  alimentation 
through  an  oesophageal  tube. 

Treatment. — In  grave  cases  attention  must  be  devoted  to 
immediate  accidents  due  to  defective  alimentation.  Subse- 
quently, the  affected  region  should  be  treated  with  electricity, 
either  by  galvanic  or  faradic  currents.  A  tonic  treatment 
should  be  prescribed,  according  to  the  nature  of  the  paralysis. 
Str3'chnine  in  pill  or  administered  subcutaneously  has  afforded 
good  results  (Simpson,  Lennox  Browne). 

3.  Recurrent  Paralysis. — It  is  well  to  recall,  that  the 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     277 

larynx  has  two  physiological  functions,  apparently  antagon- 
istic— phonation  and  respiration.  The  former  is  active  and 
voluntary  ;  the  other  usually  passive,  reflex,  and  uncon- 
scious. These  two  contrary  movements  of  the  larynx  are 
brought  about  by  two  groups  of  muscles,  well  differentiated 
— the  dilators  and  the  constrictors.  Now,  we  know  that  all 
the  laryngeal  muscles  are  constrictors,  except  the  posterior 
crico-arytaenoidei,  which  alone  draw  the  vocal  cords 
asunder,  and  assure  respiratory  functions.  Rosenbach 
has  compared  these  two  movements  to  the  flexion  and 
extension  of  the  limbs,  but  in  the  latter  two  different  nerves 
control  those  two  particular  motions.  In  the  larynx,  on 
the  contrary,  one  single  nerve  (the  recurrent)  innervates  both 
the  constrictors  and  the  dilators,  and  dominates  the  act  of 
phonation  and  respiration.  It  is  well  to  note,  that  the 
recurrent  is  not  the  only  motor  nerve  of  the  larynx,  as  the 
crico-thyroid  is  innervated  by  the  superior  laryngeal  (a  direct 
branch  of  the  pneurnogastric). 

Another  important  fact  is,  that  theary-arytsenoideus — the 
sole  odd  and  mesial  muscle — is  innervated  by  both  récurrents. 
The  anastomoses  of  those  nerves  with  the  superior  laryngeal 
must  also  be  remembered.  At  the  present  time  the  recurrent 
is  regarded  as  a  direct  emanation  of  the  internal  branch  of 
the  spinal,  as  Claude  Bernard  surmised. 

On  the  contrary,  phonation  must  derive  its  innervation 
from  a  higher  part  of  the  brain  than  the  respiratory  function. 
Speech  is  of  too  psychological  a  nature  not  to  be  derived 
from  a  central  origin.  Various  experiments  have  confirmed 
this  surmise,  and  seem  to  prove  that  the  centre  of  origin  is 
at  the  foot  of  the  third  frontal  convolution,  encroaching  a 
little  on  the  inferior  portion  of  the  ascending  frontal.  The 
centre  appears  to  be  bilateral,  as  destruction  of  the  one  is 
not  sufficient  to  annihilate  the  function  of  the  other,  a 
unilateral  excitation  having  a  bilateral  effect. 

The  route  of  the  connecting  fibres  may  be  at  the  level  of 
the  external  part  of  the  '  knee  '  of  the  internal  capsule.  It 
is  well  to  recall,  that  a  perceptible  difference  exists  between 
the    tracts    of  the   left    and   the    right    récurrents,  the    one 


278  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

winding  round  the  subclavian,  the  other  round  the  aortic 
arch. 

Recurrent  paralysis  is  the  most  important  and  the  most 
frequent  in  the  larynx.  It  may  be  unilateral  or  bilateral,  the 
former  being  the  more  frequent. 

Etiology. — Paralysis  is  due,  properly  speaking,  to  three 
causes  :  (i)  central  origin  ;  (2)  peripheral  ;  (3)  toxic  or 
infectious.  The  first  variety  is  usually  caused  by  the  various 
central  lesions  already  referred  to.  The  second  are  due 
to  lesions  occupying  one  of  the  sides  of  the  mesial  line, 
which  may  cause  irritation  or  compression  of  one  of  the 
récurrents.  Through  its  anatomical  situation  the  left  nerve 
is  more  exposed  than  the  right.  Aneurisms  of  the  aorta 
more  particularly  affect  the  left  nerve,  and  are  frequently 
revealed  by  laryngeal  examination. 

Dieulafoy  has  described,  as  aneurisms  of  a  recurrent  type, 
small  dilatations  developed  at  the  level  of  the  aortic  arch,  and 
causing  recurrent  compression,  with  loss  of  movement  in  the 
corresponding  vocal  cord.  The  vascular  dilatation  may  be 
so  developed  itself,  or  may  emit  secondary  diverticula  sufficient 
to  compress  the  right  recurrent  and  cause  bilateral  paralysis. 
Such  cases  have  been  noted  by  Munck,  Sir  Morel  1  Mackenzie, 
Cartaz,  Dezga. 

The  right  recurrent  is  exposed  from  its  situation  to  changes 
due  to  dilatations  of  the  subclavian,  and  especially  to  indura- 
tion of  the  apex  of  the  corresponding  lung. 

Sébileau  some  time  ago  demonstrated  the  intimate  relation- 
ship between  the  apex  of  the  lung  and  the  right  inferior 
laryngeal  nerve — a  relationship  which  varies  according  to 
the  subject. 

The  other  causes  liable  to  produce  recurrent  compression, 
such  as  tumours  of  the  oesophagus,  especially  cancer,  tumours 
of  the  thyroid,  fibrous  or  malignant  goitre,  and  specially 
hypertrophy  of  the  cervical  or  bronchial  glands,  may  equally 
affect  both  sides,  as  the  relationship  of  the  inferior  laryngeal 
nerves  with  those  organs  is  almost  identical. 

In  this  connection  it  is  well  to  recollect,  that  along  the 
trachea  exists  a  multitude  of  glands,  to  which  Gouguenheim, 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     279 

Barety,  and  Levai- Piquechef  have  drawn  attention,  Barety 
distinguished  two  groups  of  tracheo-bronchial  glands,  one  to 
the  right  and  the  other  to  the  left,  occupying  the  obtuse 
angle  formed  by  the  trachea  and  its  two  branches,  and  a 
third  group  at  the  level  of  the  tracheal  bifurcation,  and  finally 
interbronchial  glands  situate  at  the  divisional  angle  of  the 
iirst  four  ramifications. 

In  the  pathological  condition  those  glandular  masses  are 
sometimes  united  to  each  other  by  intermediary  glands, 
which  explains  how  hypertrophy  of  those  lymphatic  glands 
may  cause  compression  of  one  or  even  two  récurrents,  and  the 
alterations  resulting  from  them.  Similarly  may  be  explained 
the  series  of  convulsive  coughing  in  the  first  period  of  infancy, 
and  even  certain  paralyses  or  transitory  constrictions  in  the 
secondary  period  of  syphilis. 

Pneumonia  of  the  right  apex  and  pericardial  effusion  may 
produce  compression.  Baiimler  records  a  case  where  effusion 
has  given  rise  to  paralysis  of  the  two  récurrents. 

Left  recurrent  paral3^sis  is  also  met  with,  but  very  ex- 
ceptionally, in  the  course  of  pleuro-carcinomatous  effusion 
on  the  left  side.  In  an  instance  mentioned  by  Unverricht 
the  inferior  laryngeal  was  compressed  by  a  cancerous  mass 
situate  at  the  level  of  the  loop,  which  this  nerve  describes 
round  the  aorta.  The  author  even  goes  the  length  of  de- 
ducing from,  that  fact,  '  that  in  a  pleural  effusion,  suggesting 
for  some  reason  carcinoma,  the  cancerous  nature  of  the 
effusion  can  be  diagnosed,  when  paralysis  of  the  corresponding 
vocal  cord  supervenes.' 

Cases  of  paralysis  of  the  two  récurrents,  consequent  on 
compression  of  only  one  pneumogastric,  have  also  been 
mentioned;  but  it  is  more  logical  to  admit,  with  Gottstein, 
Semon,  and  others,  that  the  continuous  irritation  of  the 
pneumogastric  finally  brings  about  central  disturbances, 
which  give  rise  to  bilateral  paralysis. 

Among  secondary  causes  with  action  confined  to  a 
muscular  group  is  hysteria,  which  preferably  attacks  the 
constrictor  groups  of  both  sides,  but  may  also  act  only  on 
the  dilators,  and  sometimes  on  one  side  of  the  larynx. 


28o  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

Lead-poisoning,  diphtheria,  typhoid  fever,  syphilis,  rheu- 
matism, and  probably  influenza,  are  the  principal  toxic  causes 
of  recurrential  unilateral,  or  more  often  bilateral,  paralysis. 

Cholera,  tuberculosis,  etc.,  have  also  been  suspected. 

During  the  course  of  the  various  general  affections  there 
may  be  observed  a  true  peripheral  neuritis  of  the  recurrent, 
or  of  the  filaments  which  ramify  in  the  muscles  of  the  larynx. 
This  neuritis  may  be  attributed  to  a  mere  chill  (rheumatic 
subjects),  or  to  one  of  the  general  affections  already  referred 
to.    This  peripheral  neuritis  is  also  met  with  in  tuberculosis. 

Sex  does  not  appear  to  have  any  influence  on  the  frequency 
of  the  lesion. 

The  cause  of  the  paralysis  may  escape  the  most  careful 
examination.  The  author  has  observed  paralysis  of  the  larynx 
in  ozasnic  patients  with  laryngo-tracheal  complications.  It 
seems,  that  in  some  cases  the  laryngeal  muscles  have  partly 
lost  their  normal  tonicity,  probably  owing  to  a  tropho-neurotic 
disturbance  of  the  terminal  ramifications  of  the  two  laryngeal 
nerves  (superior  and  inferior),  as  paresis  is  almost  invariably 
accompanied  with  marked  hyposesthesia,  to  which  is  due 
the  accumulation  of  crusts  in  the  laryngo-tracheal  tract. 

Symptoms. 

(i)  Double  or  Bilateral  Paralysis  is  distinguished  by 
very  clear  functional  symptoms.  The  voice  is  stifled  or 
even  lost.  Coughing  is  likewise  aphonic,  masked,  or 
raucous.  The  patient  is  often  incapable  of  coughing  or 
expectorating,  owing  to  the  extended  dimensions  of  the 
glottic  orifice,  which  does  not  form  a  point  d'appui  for  the 
accomplishment  of  those  actions. 

The  vocal  cords  may  be  fixed  in  the  middle  line,  if  the 
lesion  is  recent.  In  that  case  marked  stertorous  and 
laboured  breathing  exists  on  inspiration  and  expiration, 
more  noticeable  during  sleep.  If  there  is  complete  paralysis, 
the  respiration  is  comparatively  easy,  except  during  exertion. 
In  these  cases  during  forced  phonation  or  coughing  there 
occurs  what  Ziemssen  calls  '  leakage  of  air  '  :  the  two  vocal 
cords  being  unable  to  adduct  closely,  the  air  filters  through 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     281 

the  space  between  them,  producing  that  characteristic  aphonic 
sonorous  sound.  During  forced  inspiration  no  true  dyspnœa 
exists,  but  a  kind  of  vibration  is  heard,  due  to  the  adduction 
of  the  free  edges  of  the  cords,  which  are  drawn  towards  the 
inferior  part  by  the  passage  of  the  air  penetrating  into  the 
bronchi. 


Fig.  139. — Position  of  the  Vocal  Cords  during  Inspiration  in 
Bilateral  Paralysis  of  the  Dilators.     (Recent  Lesion.) 

On  laryngoscopic  examination,  the  position  of  the  cords 
varies,  according  as  the  lesion  is  recent  and  incomplete  or 
old  and  complete.  In  the  former  case  the  cords  are  in  the 
middle  line,  while,  when  the  action  of  the  two  récurrents  is 
destroyed,  the  cords  assume  an  intermediary  position  between 
phonation  and  respiration  (called  the  cadaveric  position),  yet 
the  cords  are  not  so  far  apart  as  after  death.     Some  authors 


Fig.  140. — Position  of  Vocal  Cords  in  Bilateral  Paralysis  of  the 
Dilators.  Intermediate  or  Cadaveric  Position  of  the  Cords 
DURING  Inspiration.     (Old  Lesion.) 


think,  that  the  normal  tonus  of  the  crico-thyroid,  innervated 
by  the  superior  laryngeal,  is  sufficient  to  give  the  cords  a 
certain  degree  of  tension,  which  prevents  them  assuming  a 
true  cadaveric  position.  They  are  dull,  almost  grey,  leaving 
between  them  an  ellipsoidal  space,  whose  edges  are  not 
clearly  defined.      When    the   patient  is   requested   to   take 


282  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

a  deep  inspiration,  the  free  edge  of  the  vocal  cords  is  seen 
to  be  depressed  in  a  downward  direction.  The  arytenoids 
remain  immobile  during  movements  of  respiration,  as  well  as 
during  attempts  at  phonation.  The  above  symptoms  are 
characteristic  of  complete  and  bilateral  paralysis  of  the  two 
recurrent  nerves  in  adults.     In  children  the  middle  of  the 


Fig.   141. — Diagrammatic  Appearance  of  the  Immobilized  Cords  in 
THE  Cadaveric  Position.     (Seen  during  Inspiration.) 

glottic  orifice  is  so  small,  that  the  immobilization  of  the 
arytenoids  in  an  almost  mesial  position  is  sufficient  to  inter- 
fere with  respiration,  and  in  those  cases  a  more  or  less 
pronounced  dyspnoea  is  observed. 

(2)  Unilateral  Paralysis. — The  vocal  disturbances  are 
quite  different,  when  paralysis  is  merely  unilateral,  though 
complete.  The  voice  becomes  bitonal,  assuming  a  special 
timbre.       Most    frequently    the    opposite    cord,    owing    to 


Fig.   142. — Complete  Paralysis  of  the  Left  Recurrent.     (Seen 
during  Strong  Inspiration.) 

The  cord  on  this  side  is  in  the  cadaveric  position. 

exaggerated  contraction,  comes  almost  in  contact  with  the 
paralyzed  cord,  and  allows  the  edges  of  the  vibratory  part 
to  produce  a  certain  sound.  At  other  times  the  voice  is 
without  any  timbre. 

The  '  leakage  of  air  '  characteristic  of  bilateral   paralysis 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     283 

only  exists  during  efforts.     Respiration  is  normal,  because 
the  unaffected  side  is  quite  sufficient  to  ensure  respiration. 

Consequently,  laryngoscopic  examination  alone  will  almost 
settle  the  exact  diagnosis  of  the  lesion,  by  showing  a  vocal 
cord  immobilized,  either  in  the  middle  line,  or  in  a  position 
intermediate  between  phonation  and  respiration  (cadaveric 
position). 


Fig.  143. — The  same  Larynx  as  the  Foregoing.     (Seen  during 
Efforts  of  Phonation.) 

The  right  arj'tenoid  and  the  corresponding  cord,  which  are  intact,  pass 
beyond  the  middle  line,  so  as  to  compensate  for  defect  of  action  of  the 
paralyzed  vocal  cord. 

From  the  very  fact,  that  one  of  the  vocal  cords  has  lost 
its  movement,  and  the  other  has  acquired  an  exaggerated 
mobility,  the  glottic  orifice  appears  contorted  ;  the  arytenoid 
cartilage  of  the  healthy  side  overlaps  the  medial  line,  to  come 
in  contact  with  the  opposite  side,  and,  even  if  the  paralysis 


Fig.   144.  Fig,  145. 

Paralysis  of  the  left  cord  in  external  position  ;  larynx  seen  during  inspiration 
(Fig.  144)  and  during  efforts  of  phonation  (Fig.  145). 


is  old,  encroaches  over  it.     The  paralyzed  cord  seems  to  be 
shorter,  and  placed  in  a  superior  plane  to  its  fellow. 

Generally,  when  the  compression  is  recent,  the  correspond- 
ing cord,  or  both  cords  if  the  lesion  is  bilateral,  occupy  the 
middle  line,  because  the  nerves  being  irritated  induce  con- 
traction, and  the  action  of  the  constrictors  is  stronger  than 
that  of  the  dilators.     If  the  nervous  alteration  is  graver  and 


2  84  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

unilateral,  the  paralysed  cord  is  still  fixed  almost  mesially, 
both  by  the  crico-thyroid,  which,  being  innervated  by  the 
superior  laryngeal,  is  not  affected,  and  also  by  the  ary- 
arytfenoideus,  which  still  gets  its  innervation  from  the  intact 
recurrent.  Thus,  even  the  complete  suppression  of  the  recur- 
rent on  one  side  is  not  sufficient  to  put  the  corresponding 
cord  in  a  true  cadaveric  position. 

Summary. — If  the  lesion  of  the  recurrent  is  unilateral  at 
the  outset,  when  the  nerve  is  simply  irritated,  the  corre- 
sponding cord  is  fixed  in  the  middle  line,  voice  and  cough 
are  almost  normal,  respiration  is  free.  When  paral3'sis  is 
complete,  all  nervous  influx  being  suppressed,  the  cord  takes 
a  position  slightly  apart  from  the  middle  line,  a  position 
intermediate  between  phonation  and  the  true  cadaveric 
position.  The  voice  and  cough  are  then  bitonal,  with  a 
special  almost  eunuchoid  timbre. 

If  the  compression  of  the  recurrent  is  double  at  the  stage 
of  irritation,  the  cords  occupy  the  middle  of  the  glottic 
orifice  ;  the  voice  is  then  normal,  cough  somewhat  muffled, 
the  respiration  being  stridulous  and  stertorous.  The  patient 
experiences  a  sensation  of  suffocation. 

When  paralysis  is  complete,  the  cords  are  slightly  abducted 
from  the  middle  line,  aphonia  exists,  cough  is  suppressed  ; 
during  phonation  a  leakage  of  air  occurs  ;  respiratory  dis- 
turbance, at  least  m  adults,  appears  only  during  exertion. 

Pathological  Anatomy — Pathogenesis. — In  1881  Semon,  re- 
suming the  researches  of  Rosenbach,  tried  to  demonstrate 
that,  if  one  recurrent  is  suppressed,  the  corresponding  pos- 
terior crico-arytenoid  muscle  was  always  first,  and  often  the 
only  one,  paralyzed  (whence  the  mesial  position  of  the  cor- 
responding vocal  cord)  ;  then,  when  the  function  of  that 
nerve  was  completely  abolished,  either  b}'  a  long  protracted 
compression  or  by  section,  the  vocal  cord  assumed  the 
so-called  cadaveric  position. 

To  explain  that  special  position  of  the  paralyzed  vocal 
cords  in  the  middle  line,  Semon  thinks  that  the  dilator 
muscles  of  the  glottis  are  endowed  with  special  sensibility 
("posterior   crico-arytsenoidei),  which  are  often  alone  or  the 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     285 

first  to  be  affected.  Semon's  law  seems  nowadays  to  be 
confirmed — at  least,  in  its  chief  points.  Dr.  Brockaert,  in  a 
very  complete  and  recent  work,  comes  to  the  conclusion, 
that  in  the  case  of  a  bulbar  lesion  fixing  the  vocal  cord  in 
the  middle  line,  the  supposition  of  lesions  confined  to  the 
abductor  muscles  alone  (Semon)  must  be  admitted.  This 
fact  is  not  surprising,  as  the  phonatory  and  the  respiratory 
functions  are  dissociated  in  the  bulb,  and  this  selection 
occurs  in  most  of  the  cerebro-spinal  lesions. 

On  the  other  hand,  Brockaert  thinks,  it  is  not  logical 
to  admit,  that  the  dilator  muscle,  which  fulfils  the  very 
important  function  of  respiration,  is  more  vulnerable  than 
the  muscles  of  phonation — an  acquired  function. 

If  we  admit,  that  on  the  cadaver  the  posterior  crico- 
arytsenoidei  lose  their  conductibility  quicker  than  the  other 
muscles  of  the  larynx  (Semon,  Lermoyez),  it  does  not  follow, 
that  during  life  they  are  in  a  state  of  inferiority,  for  over- 
work may  account  for  their  more  rapid  death. 

According  to  Brockaert,  in  the  case  of  recurrent  lesions 
the  abductors  resist  longer  than  the  other  muscles  of  the  larynx, 
owing  to  the  fact  that  they  receive  tropJiic  fibres  from  the  sympathetic. 
This  additional  nervous  supply  explains  their  stronger  resist- 
ance to  degenerative  changes. 

To  explain  the  medial  position  of  the  cords  in  unilateral 
recurrent  paralysis,  Brockaert  thinks,  that  in  the  bulbar 
lesions,  if  the  nucleus  of  the  posterior  nerve  alone  is  affected 
and  destroyed,  a  contraction  of  the  antagonistic  muscles 
occurs,  which  may  persist.  This  contraction  conforms  with 
our  present  pathological  knowledge. 

If  the  lesion  is  peripheral,  the  cord  immediately  assumes 
an  intermediate  position,  which  he  calls  that  of  relaxa- 
tion. 

Should  the  morbid  change  be  slow,  there  is  at  first  irritation, 
which  causes  adduction  of  the  vocal  cord.  This  irritability 
may  even  persist  for  several  months  ;  then  the  nerve  gradually 
becomes  paresed,  the  nervous  conductibility  progressively 
diminishing,  until  all  the  fibres  are  affected  by  paralysis. 
The  position  of  the  cord  depends  on  the  degree  of  paresis 


286  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

of  the  nerve,  and  is  explained  by  the  fact,  that  the  adductors 
are  more  numerous  and  are  stronger  than  the  abductors.  If 
this  paralysis  is  complete,  the  so-called  intermediary  position 
(which  is  not  the  true  cadaveric  position)  may  be  explained 
by  admitting  a  muscular  tonus  in  the  antagonists,  and  par- 
ticularly in  the  ary-arytsenoideus  muscle,  whose  half  only  is 
affected  by  unilateral  compression.  The  health}'  part  of  this 
contracted  muscle  helps  to  fix  the  cord  mesially  ;  perhaps 
the  crico-thyroid,  equally  intact,  also  favours  the  protracted 
intermediate  position  of  the  cord  deprived  of  the  recurrent 
nerve  supply. 

Course  —  Duration. — The  course  and  duration  of  these 
paralyses  vary  with  their  causes.  If  it  is  a  case  of  a 
transitory  affection  and  of  short  duration,  the  function  of 
the  nerve  may  be  restored.  If,  on  the  other  hand,  the 
recurrent  has  been  long  compressed,  and  trophic  disturb- 
ances have  supervened  in  the  muscles,  the  affected  cord  runs 
the  risk  of  retaining  a  vicious  position.  Vocal  paralysis  of 
hysterical  origin  alone  is  susceptible  of  disappearing  as 
suddenly  as  it  appeared.  Usually  muscular  disturbances 
consequent  on  an  acute  affection  vanish  with  the  latter. 
Generally  at  the  outset  of  recurrent  lesions  (compression) 
are  observed  phenomena  of  excitation,  and  contraction, 
more  or  less  transitory  (spasmodic  cough,  aphonia,  etc.). 
Then,  as  the  nerve  filaments  are  more  compressed,  pro- 
gressive motor  paralysis  takes  place,  as  well  as  atrophy  of 
the  muscles  innervated  by  the  affected  nerve. 

Diagnosis. — Diagnosis  of  the  lesion  itself  is  generally  easy. 
Functional  disturbances  on  the  one  hand,  and  laryngoscopic 
examination  on  the  other,  permit  the  nature  of  the  muscular 
lesions  being  recognized.  On  the  contrary,  it  is  not  always 
easy  to  determine  the  cause  of  the  paralysis.  When  the 
left  cord  is  affected,  it  must  be  ascertained,  whether  the 
compression  is  due  to  the  aorta,  the  heart,  or  to  the  oeso- 
phagus. If  it  is  the  right  cord,  the  subclavian,  or  the  lungs, 
a  tumour  of  the  mediastinum,  and  even  of  the  oesophagus, 
may  be  suspected. 

In  hysteria  paralysis  is  usually  bilateral.      In   inflamma- 


DISEASES  AXD  TRAUMATISMS  OF  THE  LARYNX     287 

tory  paralysis  the  presence  of  laryngeal  catarrh  suggests  the 
diagnosis.  Finally,  when  it  is  impossible  to  discover  the 
exact  nature  of  the  paralysis,  the  explanation  of  the  phe- 
nomenon may  be  sought  in  the  central  nervous  system,  or 
in  the  general  condition  of  the  patient.  It  must  be  remem- 
bered, that  in  some  cases  the  motor  disturbance  of  the 
larynx  is  a  premonitory  symptom,  which  for  long  precedes 
other  disturbances  of  a  bulbar  or  cerebral  lesion.  Cicatrices, 
proceeding  from  old  affections  of  the  larynx,  and  causing 
ankylosis  of  the  crico-arytenoid  articulations,  are  revealed 
by  the  existence  of  fibrous  adhesions,  which  are  usually 
visible  on  direct  examination. 

Arthritis  of  tuberculosis  and  syphilis  is  likewise  accom- 
panied by  concomitant  lesions,  revealing  their  nature. 

Immobility  due  to  neoplasms  is  always  associated  with 
tumefaction  of  the  posterior  periarytenoid  region,  or  of  the 
ventricular  band,  which  precludes  the  hypothesis  of.  a  simple 
paralysis.  Care  must  be  taken  not  to  confuse  certain  glottic 
spasms,  due  to  the  emotion  of  the  patient  at  the  time  of  the 
examination  of  his  larynx,  with  a  true  paralysis.  It  will  be 
sufficient  to  place  the  mirror  in  position  repeatedly,  and  to 
ask  the  patient  to  breathe  calml}^ 

In  transitory  contraction  of  the  adductors  the  cord  is,  as 
it  were,  shrivelled,  its  edge  concave,  the  arytenoid  being 
drawn  downwards  and  inwards.  The  affected  cord  seems  to 
be  shorter  than  the  other.  The  contracted  vocal  cord  is  not 
only  beyond  the  middle  line,  but  also  above  that  of  the 
other  side. 

During  inspiration  the-  contracted  arytenoid  remains  com- 
pletely immobile,  whereas  in  unilateral  paralysis  it  undergoes 
at  its  top  small  oscillations  due  to  the  integrity  of  the  half 
of  the  arytaenoideus  muscle. 

Diagnosis  of  paralysis  is  chiefly  made  by  requesting  the 
patient  to  carry  out  the  movements  of  phonation  and  in- 
spiration.    An  expert  will  generally  recognize  it  easily. 

Prognosis. — The  gravity  of  paralysis  of  laryngeal  muscles 
depends  on  the  cause  of  the  lesion.  If  the  paralysis 
occupies   the    two    cords,    both    being    in   the    middle    line, 


288  DISEASES  OF  THE  PHARYXX  A\W  LARYXX 

respiration  is  accordingly  involved,  and  tracheotomy  must 
be  carried  out  to  save  the  life  of  the  patient.  Even  in 
hysteria  it  may  be  necessary  to  open  the  air  tract  to  prevent 
asphyxia,  but  such  cases,  by  no  means  rare,  are  due  to  con- 
traction rather  than  paralysis. 

In  the  case  of  unilateral  lesions  life  is  generally  not  en- 
dangered. Prognosis  then  depends  on  the  nature  and  the 
cause  of  the  laryngeal  motor  disturbance. 


ISOLATED    PARALYSIS    OF   THE    DILATOR  AND    CONSTRICTOR 

GROUPS. 

This  is  met  with  almost  solely  in  hysteria.  In  this  case 
it  is  bilateral,  and  extends  separately  to  each  of  the  muscular 
groups  of  the  larynx. 

(a)  Dilators. — When  paralysis  attacks  the  posterior  crico- 
ar3'tenoidei  (dilators),  the  fimctional  and  objective  symptoms 
are  those  of  double  recurrent  paralysis  at  its  outset.  The 
vocal  cords,  placed  in  an  intermediate  position,  almost  com- 
pletely block  the  air  passage.  The  voice  is  suppressed,  and 
during  phonation  a  characteristic  leakage  of  air  is  perceived. 
.If  the  loss  of  movement  persists,  tracheotomy  should  be 
performed  to  prevent  asphyxia.  This  form  of  hysteric 
disturbance  is  fortunately  rare. 

(b)  Constrictors. — When  the  loss  of  movement  affects 
the  group  of  the  constrictors,  the  symptoms  are  quite 
different.  There  is  complete  aphonia,  the  patient  being 
unable  to  adduct  his  vocal  cords,  and  during  efforts  of 
phonation  the  air  is  heard  passing  through  the  glottic  orifice, 
which  is  enlarged  from  the  want  of  adduction. 

Cough,  when  it  exists,  follows  the  modification  of  the 
voice.  It  is  rather  a  tracheal  '  blowing,'  deprived  of  any 
sonorous  quality.  Expectoration  is  generally  nil,  and  in  any 
case  very  difficult.  The  tactile  sensibility  of  the  lar3mgo- 
tracheal  mucosa  is  almost  always  changed.  Respiration  is 
normal.  It  is  even  very  eas}^  as  the  vocal  cords  remain  in 
the  respiratory  position. 

If  the  lesion  is   unilateral,  the  voice  and  the   cough   are 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     289 

altered  in  their  timbre,  in  spite  of  the  compensation  supplied 
by  the  healthy  side. 

Laryngoscopic  examination  during  phonation  shows,  that 
the  epiglottis  fails  to  rise  normally,  the  vocal  cords  remain- 
ing apart  from  each  other.  The  glottic  orifice  assumes  the 
appearance  of  an  isosceles  triangle,  with  a  posterior  base 
(arytenoid),  the  lateral  edges  of  which  are  slightly  incurved. 
From  this  position  it  follows,  that  the  two  posterior  angles 
are  rounded,  the  anterior  alone  retaining  its  regular  form. 

During  inspiration  the  two  thyro-arytenoid  folds,  abduct- 
ing slightly,  become  more  rectilinear,  and  make  the  triangle 
more  isosceles  than  during  the  efforts  of  phonation. 

If  the  paralysis  is  unilateral,  the  glottic  orifice  appears 
deviated.  One  of  the  cords  remains  immobile  in  an  ex- 
ternal position,  whereas  the  other  endeavours  to  approach 
its  fellow,  and  almost  overlap  the  mesial  line.  To  this 
compensation,  supplied  by  the  sound  side,  must  be  attri- 
buted the  asymmetrical  appearance  of  the  larynx,  noticeable 
especially  during  phonation.  Frequently  the  ary-arytas- 
noideus  muscle,  paralyzed  on  one  side,  half  contracts,  causing 
the  arytenoid  of  the  paralyzed  side  to  overbalance,  giving  the 
cartilage  a  deformed  look,  and  making  the  posterior  region 
appear  swollen. 

Isolated  Paralysis  of  the  Muscles  of  the  Larynx. 
— Hitherto  we  have  considered  the  two  muscular  groups  as 
a  whole,  but  it  may  happen,  that  under  certain  influences 
the  paralysis  is  confined  to  an  individual  muscle  of  the 
larynx.  In  that  case  laryngoscopic  examination  generally 
shows  the  paralytic  disturbance  clearly  enough  to  make 
the  diagnosis  easy. 

General  Etiology. — Isolated  paralysis  of  the  muscles  of  the 
larynx  has  an  etiology  almost  identical  with  that  of  the  re- 
currents.  It  may  be  of  central  origin,  occasioned  by  peripheral 
neuritis,  or  consequent  on  primary  myopathy  (Sir  Morell 
Mackenzie).  It  is  sufficient  to  recall  the  anatomical  position 
of  the  thyro-arytaenoidei  or  ary-arytaenoidei  to  understand 
that  they  may  be  paralyzed  when  their  mucosa  is  the  seat  of 
a  more  or  less  active  infection. 

19 


290  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

Rheumatism  may  also  be  confined  to  a  group,  or  even  to  a 
single  muscle  of  the  larynx,  and  cause  isolated  functional 
inability  of  the  affected  part.  Before  attributing  the  paralysis 
to  rheumatism,  it  is  necessary  to  ascertain,  if  the  lesion  cannot 
be  explained  otherwise.  Finally,  it  must  be  recalled,  that 
hysteria  is  by  far  the  most  common  cause  of  isolated  larjmgo 
plegia. 

Paralysis  of  the  Lateral  Crico  -  arytaenoidei  is 
fairly  rare,  although  Elsberg  has  recorded  some  cases. 
When  the  two  muscles  are  affected,  the  functional  symptoms 
are  those  of  paralysis  of  the  constrictors.  The  patient  is 
completely  aphonic.  Respiration  is  easy,  and  coughing 
follows  the  modification  of  the  voice. 

For  this  reason  some  authors  think,  that  it  cannot  be 
affirmed,  that  the  lateral  crico-arytsenoidei  alone  are  affected. 
Laryngoscopic  examination  shows,  instead  of  the  image  of 
the  paralysis  of  the  constrictors,  a  glottic  orifice  assuming 
a  rhomboid  form.  On  attempted  phonation,  the  vocal 
cords  posteriorly  are  in  contact  owing  to  the  contraction  of 
the  transverse  muscles,  but  are  separated  throughout  the 
rest  of  their  extent,  which  gives  the  larynx  a  characteristic 
aspect.  If  paralysis  is  unilateral,  one  of  the  vocal  cords 
is  perfectly  tense  antero-posteriorly,  overlapping  the  middle 
line  even  during  phonation,  whereas  the  other  presents 
the  characteristics  of  paralysis  of  the  lateral  crico-arytce- 
noideus,  the  vocal  cord  forming  an  angle  towards  its 
posterior  third,  which  at  this  level  remains  apart  from  its 
fellow. 

Paralysis  of  the  Thyro  -  arytenoid  Muscle  — 
Etiology. — To  the  general  causes  referred  to  above  must  be 
added  acute  or  chronic  inflammation  of  the  vocal  mucosa, 
which  is  common  in  speakers,  singers,  preachers,  and  rheu- 
matic people,  for,  owing  to  its  situation,  the  thyro  arytœ- 
noideus  is  very  much  exposed  to  inflammatory  paralysis. 

Symptoms. — The  thyro-arytenoidei  may  be  attacked  uni- 
or  bilaterally.  In  complete  paralysis  the  voice  is  husky, 
dysphonic,  or  even  diaphonie.  If  the  patient  emits  two 
sounds  simuitaneoush',   those  sounds  are  almost   always  in 


DISEASES  AXD  TRAUMATISMS  OF  THE  LARYXX     291 

harmony,  and  generally  at  an  octave  or  a  third  from 
each  other.  They  are  due  to  the  incomplete  contraction 
of  the  thyro-ar\-tasnoideus,  and  to  the  union  of  the  cords 
either  in  the  anterior  third  or  even  in  the  posterior  fourth; 
hence  are  formed  two  glottic  orifices  of  unequal  dimen- 
sions. If  paralysis  is  complete,  the  voice  is  broken  and 
aphonic,  and  in  such  cases  all  the  vocal  modifications  are 
observed,  as  already  recorded  under  catarrhal  laryngitis. 

Respiration,  on  the  other  hand,  is  easy.  Cough  is  depen- 
dent on  the  cause  of  the  paralysis.  Laryngoscopic  examina- 
tion shows  the  vocal  cords  assuming  a  wavy  form,  adducted 
in  some  places,  and  leaving  in  others  free,  sinuous,  and  loose 
spaces.     The  glottic  orifice  has  an  irregular  form  from  the 


Fig.  146. — Diagrammatic  Appearanxe  of  the  Laryxx  during 
Efforts  of  Phonation. 

The  edge  of  the  cords  is  usually  less  defined  and  more  wavy. 


anterior  commissure  of  the  cords  to  their  cartilaginous 
insertion  on  the  arytenoid. 

The  edge  of  the  vocal  cords  is  covered  with  more  or  less 
thick  creamy  mucus,  which  becomes  frothy,  and  collects  on 
those  parts  of  the  thyro-arytenoid  folds  which  come  into 
contact  during  phonation.  If  the  paralysis  is  of  inflamma- 
tory origin,  the  mucosa  is  very  often  rosy,  even  red  and 
inflamed.  It  is  not  rare  to  find  paresis  or  paralysis  of  the  ary- 
arytaenoidei  associated  with  that  of  the  thyro-arytsenoidei. 

Finally,  on  laryngoscopic  examination  the  ventricular 
bands  are  often  seen  during  phonation  to  approach  and 
come  in  contact  in  their  endeavour  to  fulfil  to  a  certain 
degree  the  function  of  the  true  cords. 

The  muscular  disturbance   may  be   more   pronounced  on 

ig — 2 


292  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

one  side  than  on  the  other,  but  it  is  rare  that  both  sides  are 
not  affected  at  the  same  time. 

Diagnosis  is  generally  easy  on  direct  examination.  Paraly- 
sis of  the  crico-thyroidei  may  be  mistaken  for  paralysis  of 
the  intrinsic  muscles  of  the  vocal  cords,  but  in  those  cases 
the  cords  are  simply  grey  and  dull  in  colour,  and  do  not 
present  that  irregular  and  inflamed  appearance  which  dis- 
tinguishes paralysis  of  the  thyro-arytenoidei. 

Prognosis  of  paralysis  of  the  thyro-arytenoideus  varies  with 
the  cause  producing  it.  It  is  grave  in  professional  singers  and 
speakers,  as  the  voice  loses  its  purity  and  sonorous  quality. 

Paralysis  of  the  Ary-arytasnoideus. — The  causes 
of  the  paralysis  of  this  muscle  are  those  already  given 
in  the  case  of  isolated  paralysis  of  the  laryngeal  muscles. 


Fig.   147.  — Diagrammatic  Appearance  of  the  Larynx  in  Paresis 

OF    THE    ArY-ARYT^NOIDEUS. 

Symptoms. — Authors  are  in  disagreement  regarding  the 
vocal  disturbances  consequent  on  isolated  paralysis  of  the 
ary-arytasnoideus.  According  to  Mandl,  only  the  upper 
register  of  the  voice  is  lost,  while  Elsberg  maintains  that 
raucity  and  hoarseness  alone  exist.  The  author  has  always 
observed  absolute  aphonia  in  complete  paralysis.  Although  the 
vocal  cords  adduct  exactly  in  their  two  anterior  thirds,  the 
patient  is  as  aphonic  as  in  paralysis  of  the  constrictors. 
It  is  only  when  the  muscle  is  merely  paresied  or  half 
paralyzed,  that  the  voice  becomes  raucous  and  not  aphonic. 
It  may  be  stated,  that  the  degree  of  arytenoid  paralysis  can 
be  gauged  by  the  modifications  of  the  vocal  timbre.  Cough- 
ing follows  the  modifications  of  the  voice,  and  is,  according 
to  circumstances,  sonorous,  raucous,  croupous,  or  aphonic. 
Deglutition  is  by  no  means  interfered  with.  Respiration  is 
normal,  but  slightly  troublesome  in  children  during  the  night. 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     293 

owing  to  the  swelling  of  the  interarytenoid  mucosa,  which  in 
their  case  often  accompanies  this  paralysis.  On  laryngoscopic 
examination,  if  the  practitioner  bears  in  mind  the  situation  of 
the  ary-arytenoid  muscle  and  its  physiological  function,  he 
will  understand  the  disturbances  following  on  its  want  of 
action.  If  paralysis  is  complete,  the  two  arytenoids  are  seen 
during  phonation  to  remain  apart  from  one  another,  almost 
in  the  inspiratory  position.  The  diagrammatic  laryngoscopic 
image  is  a  glottic  triangle,  with  the  base  posteriorly,  and  an 
apex  ascending  towards  the  posterior  or  anterior  third  of  the 
vocal  cords.  Unfortunately,  this  aspect,  apparently  character- 
istic of  ary-arytsenoideus  paralysis,  is  not  seen  in  practice. 
There  is  always  observed  a  kind  of  exaggerated  contraction 
of  all  the  accessory  muscles  of  the  larynx,  which  shrivels  the 


Fig.   148. — Appearance  of  the  Laryngoscopic  Image  in  Complete 
Paralysis  of  the  Ary-aryt^noideus.     (Moure). 

organ,  and  not  only  raises  the  ventricular  bands  above  the 
vocal  cords,  but  also  markedly  lowers  the  epiglottis,  and  makes 
it  almost  impossible  to  see  the  ary-arytenoid  region.  The 
arytenoids  are  separated  during  inspiration,  while  anteriorly 
the  glottic  triangle  is  scarcely  open.  If  paralysis  is  incom- 
plete, the  vocal  cords  are  in  contact  almost  up  to  their 
posterior  part,  leaving,  however,  between  them  at  this  level 
a  noticeable  space.  The  larynx  is  then  less  shrivelled,  the 
epiglottis  is  less  depressed,  and  it  is  generally  easier  to  see 
the  posterior  glottic  triangle,  with  an  apex,  which  is  the 
more  anterior  as  the  paresis  is  the  less  complete.  The  slight 
phonetic  disturbances  observed  by  Elsberg  refer  to  such 
cases. 

Diagnosis. — This  paralysis  is  sometimes  difficult  to  recog- 
nize.    Indeed,  the  larynx  is  so  folded  on  itself  during  phona- 


294  DISEASES  OF  THE  PHARYXX  AXD  LARYNX 

tion,  that  the  mucosa  appears  red,  turgescent,  and  swollen. 
Consequent!}-,  a  complete  paralysis  of  the  ary-arytœnoideus 
is  liable  to  be  confused  with  an  cedematous  inflammatory 
laryngitis.  To  establish  the  true  nature  of  this  disease, 
request  the  patient  to  breathe  several  times,  to  see  whether 
the  swelling  disappears  during  normal  respiration,  whether 


h      i 


BXBJ^AJr^ 


Fig.  149. — Diagram  of  Paralysis  of  the  Muscles  of  the  Larynx, 
(After  Elsberg.) 

The  first  row  comprises  paralysis  indicated  by  phonatory  '  leakage  '  ;  the 
second  to  the  left  =  5  (fl  and  h),  parah"sis  of  the  dilators,  recent  and  old  ; 
the  figure  on  the  right  (2  x  3  x  4  x  5),  paralysis  of  the  constrictor  muscles. 
The  cords  remain  immobile  during  phonation  and  inspiration. 

Isolated  Paralysis. — i,  Paralysis  of  the  crico-thjToideus  tensors  (the 
cords  are  sinuous)  ;  2,  parah'sis  of  the  thyro-ar3-t2enoidei  ;  3,  paralj^sis  of 
the  ary-arj-taenoideus  ;  4,  parah"sis  of  the  lateral  crico-arj-tsenoidei. 

Combined  Paralysis. — 2  x  3,  Paralysis  of  the  thyro-arj-tœnoidei  and  of  the 
arj'-arytœnoideus  ;  2x4,  parah-sis  of  the  thyro-arytœnoidei  and  of  the 
lateral  crico-arytsenoidei  ;  3  x  4,  paralysis  of  the  lateral  crico-arj-tsenoidei 
and  of  the  arj'-arytsenoideus  ;  2x3x4,  parah-sis  of  the  lateral  crico 
ar3-tasnoidei,  the  thyro-arytœnoidei,  and  the  ary-arj-tsenoideus  ;  1x2x3x4, 
paralj'sis  of  all  the  constrictors;  5  (a  and  h),  paralysis  of  the  dilators; 
2x3x4x5,  paralysis  of  all  the  muscles  of  the  larynx. 

the  arytenoids  move  to  and  fro  physiologically,  or,  on  the 
contrary,  remain  immobile  during  phonation  or  quiet 
respiration. 

Interarytenoid  tumours,  or  infiltrations  preventing  the 
adduction  of  the  arytenoids,  are  easily  perceptible  on  direct 
examination,  their  existence  precluding  the  diagnosis  of 
simple  paralysis. 


DISEASES  AXD  TRAUMATISMS  OF  THE  LARYNX     295 

Double  ankylosis  is  accompanied  by  evident  symptoms,  on 
which  it  is  needless  to  dwell. 

Course  and  Duvation  depend  absolutely  on  the  nature  of 
the  affection  and  on  its  cause.  If  the  malady  is  of  a  catarrhal, 
inflammatory  origin,  it  is  usually  of  short  duration.  If  it  is 
due  to  h3-steria,  the  motility  reappears  as  rapidly  as  it 
vanished. 

Prognosis  also  depends  on  the  etiology  of  the  muscular  dis- 
turbance.. 

Treatment  of  the  Laryngeal  Paralysis. 

Treatment  should  be  directed  to  the  cause  of  the  paralysis. 
Should  the  muscular  disturbance  be  connected  with  a  general 
affection  (hysteria,  rheumatism),  the  latter  should  be  com- 
bated by  suitable  means.  When,  on  the  contrary,  it  is  conse- 
quent on  compression,  the  cause  should  be  removed  if  pos- 
sible. This  is  the  only  means  of  curing  the  disease,  but  in 
many  cases,  however,  it  cannot  be  effected. 

Local  treatment  in  inflammator}'  cases  consists  of  rest, 
sprays,  painting  the  cords  with  solutions  of  zinc  chloride, 
nitrate  of  silver,  etc.  If  such  treatment  fails,  resort 
should  be  had  to  external  massage  with  the  hand  or  electric 
motor,  or  to  the  use  of  the  faradic  or  continuous  current. 
Electricity  can  be  used  from  the  first  externally,  the  two 
poles  being  placed  on  the  paralyzed  muscles.  If  the  con- 
strictors are  paralyzed,  one  of  the  poles  should  be  placed  on 
the  nape  of  the  neck,  the  other  in  front  of  the  larynx,  or 
successively  on  the  sides  of  the  neck  at  points  corresponding 
to  the  arytenoids.  The  electrode  may  also  be  applied  on 
each  side  of  the  larynx  towards  the  arytenoid  region.  During 
treatment  the  patient  should  be  asked  to  use  his  voice,  and 
pronounce  as  loud  and  as  slowly  as  possible  the  vowels,  and 
sometimes  even  long  full  sounds,  and  run  over  the  gamut, 
making  at  each  sound  a  protracted  and  profound  inspiration. 

In  hysterical  paral3'sis  it  is  not  uncommon  to  observe  on 
the  sides  of  the  larynx  vibrating  areas,  the  compression  of 
which  is  sufficient  to  restore  the  vocal  integrity.  In  some 
cases,  by  raising  the  head  and  drawing  the  cricoid  to  the 


igô 


DISEASES  OF  THE  PHARYNX  AND  LARYNX 


thyroid,  the  normal  timbre  of  the  voice  is  obtained,  whereas 
in  other  patients  the  very  opposite  has  to  be  done — the 
approximation  of  the  thyroid  to  the  cricoid. 

It  is  difficult  to  mention  all  the  modes  of  treatment  applic- 
able to  those  paralyses,  as  the  most  unlikely  means  often 
succeed  where  rational  treatment  fails. 

In  some  cases  the  different  external  methods  referred  to 
do  not  succeed,  in  spite  of  frequent  painstaking  application. 
Recourse  must  then  be  had  to  endolaryngeal  electrical 
treatment,  by  placing  a  pole  at  the  level  of  the  pomum 
Adami,  while  the  other  is  directed  to  the  cords  themselves, 
or  by  using  a  double  electrode  placed  posteriorly  on  the 
larynx  or  even  on  the  vocal  cords. 


Fig.  150. — Double  Intra-laryngeal  Electrode. 
A,  Conducting-rod  ;  B,  the  inner  part  ;  X,  the  connecting-points. 

The  intensity  of  the  current  must  be  proportional  to  the 
degree  of  paralysis  and  the  resistance  and  endurance  of  the 
patient.  Once  contact  is  established  the  voice  is  restored. 
This  treatment  is  ineffectual  in  grave  paralysis  of  myopathic 
origin,  or  in  that  due  to  central  disturbances  or  to  com- 
pressions of  long  duration.  It  is  ver}'  successful  in  neuro- 
pathic forms.  In  man}'  cases  the  resultant  disturbances, 
and  not  the  paralysis,  should  be  kept  in  view.  When  the 
two  dilators  are  affected,  respiration  is  so  compromised  that 
tracheotomy  must  be  carried  out. 

In  doubtful  forms,  where  the  cause  of  the  loss  of  movement 
is  not  readily  determined,  a  mixed  treatment  (biniodide)  or 
painting  with  iodine  over  the  tract  of  the  récurrents  should 
be  prescribed,  and  salicylate  of  soda  administered  in  suspected 
cases  of  rheumatism. 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     297 


Spasm  of  the  Laryngeal  Muscles. 

Under  this  name  is  designated  a  transitory  or  permanent 
contraction  of  one  or  of  all  the  muscles  of  the  larynx.  These 
spasms  may  be  classified  as  follows:  (i)  Functional  spasm; 
(2)  due  to  direct  irritation  ;  (3)  of  peripheral  origin  ; 
(4)  of  central  origin  ;  (5)  reflex  ;  (6)  spasm  associated  with  a 
general  affection. 

Functional  Spasm,  or  Spasm  of  the  Muscles  of 
Phonation,  comprises  professional  cramp  of  the  muscles 
concerned  in  phonation.  This  affection  is  known  under 
different  names — e.g.,  contraction  of  the  phonatory  muscles 
(Elsberg);  phonic  spasm  (Koch);  mogiphonia,  or  voice  fatigue 
(B.  Fraenkel,  Bresgen)  ;  dysphonia  spastica  (Schech). 

Etiology. — This  neurosis  is  generally  the  result  of  ex- 
aggerated vocal  fatigue.  The  phonic  spasm  may  be  com- 
pared with  writer's,  musician's,  or  phonographer's  cramp. 
Hysteria  must  also  be  taken  into  account.  At  other  times 
the  explanation  of  the  disturbance  must  be  sought  for  in  the 
nasal  fossae.  Thus,  this  neuro-muscular  reflex  may  be  a 
result  of  polypoid  degeneration,  hypertrophy,  or  various 
tumours  of  the  Schneiderian  membrane  (Bresgen).  Acute 
pharyngitis  or  laryngitis  often  gives  rise  to  this  affection. 
Goitre  has  also  been  suspected  as  a  cause,  but  probably  it 
may  have  been  a  question  of  true  irritation  of  the  récurrents. 
Finally,  phonic  spasm  may  be  of  central  origin. 

Symptoms. — The  chief  functional  symptom  is  alteration  of 
the  voice,  which  results  from,  the  sudden  exaggerated  con- 
traction of  the  muscles  of  phonation.  When  the  patient 
wishes  to  emit  a  sound — speak,  read  aloud,  or  sing — the  sound 
is  choked,  frequently  only  half  pronounced,  or  even  not  at 
all.  There  occurs,  as  Koch  aptly  remarks,  a  true  stammering 
of  the  vocal  cords. 

Aphonia  is  usually  complete.  The  patient  gives  one  the 
impression  of  making  exaggerated  efforts  to  contract  his  vocal 
cords,  without  being  able  to  utter  a  sound.  The  alterations 
of  the  voice  vary,  according  as  the  spasm  is  transitory  or 


298  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

permanent.  It  generally  affects  the  phonatory  muscles,  and 
consequently  vocal  distubances  are  the  chief  symptoms. 

Coughing,  laughing,  and  whispering  are  effected  normally, 
except  in  grave  cases.     Respiration  is,  as  a  rule,  intact. 

On  laryngoscopic  examination  during  rest,  the  laryngeal 
mucosa  seems  to  be  healthy.  It  is  only  during  phonation 
that  the  vocal  cords  are  seen  to  contract  and  adduct  briskly 
and  energetically,  and  even  encroach  on  one  another.  When 
the  spasm  is  localized  to  the  posterior  ary-arytsenoidei  or  to 
the  thyro-arytsenoidei,  there  occur  series  of  transitory  images, 
very  variable  in  their  form.  Sometimes  the  two  arytenoids 
are  seen  to  rub  energetically  against  each  other,  causing  the 
abrupt  adduction  of  the  cords  posteriorly.  At  other  times 
the  lips  of  the  glottis  come  in  contact  antero-posteriorly, 
while  posteriorly  they  remain  open.  This  spasmodic  con- 
traction, which  prevents  the  formation  of  the  glottic  '  reed,' 
and  explains  the  special  and  characteristic  aphonia  of  those 
cases,  is  easy  to  observe. 

Course,  Duration,  Termination. — The  course  depends  on 
the  cause  of  the  disease.  The  spasm,  generally  mild  at  its 
outset,  may  increase,  if  the  patient  does  not  take  precautions 
to  arrest  it.  In  nervous  subjects  a  violent  emotion  is  very 
often  sufficient  momentarily  to  intensify  the  muscular  dis- 
turbance. The  duration  is  therefore  extremely  variable. 
Transitory  in  some  cases,  it  sometimes  becomes  obstinate, 
and  may  last  for  months,  even  years.  Cure,  as  a  rule,  takes 
place. 

Prognosis  is  grave,  especially  in  professionals,  because,  if 
it  is  always  possible  to  effect  a  cure  by  appropriate  treatment, 
relapses  are  liable  to  occur.  When  those  disturbances  are 
of  a  neuropathic  or  nasal  origin,  the  prognosis  is  more 
favourable.  If  they  are  the  result  of  vocal  fatigue,  they 
usually  disappear  after  a  more  or  less  protracted  rest. 

Diagnosis  is  easy,  because  the  modifications  of  the  voice 
and  the  results  furnished  by  examination  of  the  larynx  are 
so  characteristic,  that  spasmodic  aphonia  cannot  be  confused 
with  any  other  lesion. 

Treatment. — The  cause  of  the  disease,  if  known,  should  be 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     299 

attended  to.  Generally  speaking,  rest  is  the  first  considera- 
tion. Methodical  exercise  of  the  voice,  preceded  by  regular 
and  rhythmic  respiratory  practice,  singing,  massage  of  the 
larynx,  or  electricity  (preferably  the  continuous  current), 
should  be  recommended. 

Hydrotherapy,  painting  of  the  laryngeal  mucosa  with  a 
solution  of  cocaine  (i  in  10)  may  also  be  tried,  while,  accord- 
ing to  the  cases,  bromide  of  potash,  valerianate  of  ammonia, 
or  merely  tonics,  should  be  internally  administered. 

If  the  lesion  is  of  nasal  origin,  the  nasal  mucosa  should  be 
attended  to.  With  a  little  patience,  a  definite  cure  will 
gradually  be  obtained. 

Eunuchoid  Voice. —  Occasionally  in  certain  male  adults 
at  puberty,  the  voice,  instead  of  changing  its  timbre  and 
becoming  deeper,  retains  an  acute  infantile  tone.  Some- 
times the  youth  seems  to  be  affected  with  catarrhal  laryngitis 
and  consequent  muscular  disturbances.  Thus,  during  the 
pronunciation  of  a  sentence  he  at  one  time  emits  a  deep  and 
raucous  sound  and  at  another  a  falsetto  note.  There  exists, 
as  it  were,  a  vocal  disorganization,  through  asynergia  of  the 
muscles  controlling  the  movements  of  the  cords  during 
phonation.  This  eunuchoid  voice  is  usually  produced  through 
functional  irregularity  of  the  laryngeal  muscles,  the  subject 
affected  being  able  to  use  only  a  limited  part  of  the  vocal 
'  reed.'  It  is  equally  observed  in  youths  of  seventeen  or 
eighteen  years  of  age,  whose  voices  have  broken  rapidly,  and 
whose  vocal  cords,  being  suddenly  lengthened,  have  not  had 
time  to  get  accustomed  to  the  new  condition. 

Ruault  thinks,  that  the  eunuchoid  voice  is  sometimes  the 
result  of  arrest  in  the  development  of  the  larynx  at  the 
time  of  puberty,  but  the  author's  experience  does  not  accord 
with  that  theory.  Besides,  all  cases  observed  by  him  have 
been  cured  in  a  few  days  by  regular  and  rational  treatment. 

Treatment  consists  in  vocal  gymnastics.  The  patient 
should  be  taught  to  breathe  profoundly,  and  then  to  lower 
the  head,  with  the  chin  downwards,  so  as  to  relax  the 
vocal  cords.  Once  in  this  position  he  should  emit  a  deep 
chest  sound.     If  need  be,  the  emission  of  this  sound  could 


300  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

be  facilitated  by  approximating  the  cricoid  cartilage  to  the 
thyroid.  As  soon  as  the  deep  sound  is  obtained,  the  patient 
should  pronounce  a  syllable  in  the  same  tone,  then  some 
words  slowly  articulated,  and  afterwards  a  whole  sentence. 
The  voice  soon  changes  its  timbre  and  becomes  deep, 
because  large  laryngés  (baritones  and  basses)  are  chiefly 
exposed  to  this  disease. 

Spasms  through  Direct  Irritation. — These  are  ob- 
served in  the  course  of  acute  inflammation  of  the  mucosa 
in  predisposed  nervous  subjects.  Thus,  they  are  frequent  in 
children  affected  with  acute  laryngeal  catarrh.  They  may 
even  become  so  intense  in  those  cases,  that  they  merit  a 
special  description. 

Stridulous  Laryngitis. — The  acute,  abrupt  œdema  of 
the  vocal  mucosa,  acting  like  a  foreign  body,  may  give  rise 
to  spasms.  Voluminous  pedunculated  tumours  are  liable  to 
titillate  the  vocal  mucosa,  and  occasion  spasm  of  the  cords. 
The  laryngeal  mucosa  soon  becomes  accustomed  to  the 
friction,  which  no  longer  causes  reflex  phenomena.  When 
the  neoplasm  is  bulky  enough  to  interfere  with  the  entrance 
of  the  air  into  the  tract,  the  spasm,  no  matter  how  light, 
only  increases  the  respiratory  stenosis.  Foreign  bodies,  at 
the  moment  of  their  introduction  into  the  respiratory  canal, 
violently  excite  the  laryngeal  sphincter,  and  cause  a  more 
or  less  acute  spasm,  according  to  the  nature  of  the  body. 

Liquids  may  cause  choking  {engouement — i.e.,  a  spasmodic 
cough,  which  generally  abates  in  a  few  moments).  This  phe- 
nomenon specially  occurs,  when  the  liquids  penetrate  into  the 
posterior  inter-arytenoid  region.  Inhalation  of  irritating  dust 
or  vapour — sulphuric  acid,  ipecacuanha  powder,  etc.,  occasions 
also  a  true  momentary  choking.  Certain  topical  applications 
voluntarily  introduced  into  the  larynx  may  also  cause  spasm — 
e.g.,  concentrated  solutions  of  chromic  acid,  nitrate  of  mercury, 
nitrate  of  silver,  lactic  acid,  etc.  Those  spasmodic  onsets  are 
most  frequent  in  patients  with  obstructed  nasal  fossae,  whose 
vocal  mucosa  is  being  treated  for  the  first  time.  They  may 
sometimes  become  so  violent,  as  to  frighten  an  inexperienced 
practitioner.     This  transitory  contraction  of  the  laryngeal 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     301 

muscles  may  be  observed  in  nervous  subjects,  on  painting 
the  pharynx,  or  on  forcibly  depressing  the  tongue  during 
inspiration. 

Symptoms. — The  spasm  due  to  direct  irritation  charac- 
teristically occurs  at  the  exact  moment  when  one  of  the 
above  causes  is  present.  Consequently  its  onset  is  abrupt. 
It  is  sometimes  ushered  in  by  a  tickling  sensation,  causing 
fits  of  coughing,  which  consists  of  a  series  of  rapid  expira- 
tions, followed  by  a  sonorous  whistling  characteristic  inspira- 
tion. Expiration  is  short  and  inadequate,  the  patient  with 
great  difficulty  endeavouring  to  inspire  again.  If  this  con- 
dition persists,  the  face  becomes  congested  ;  asphyxia,  and 
even  death,  may  ensue. 

Course,  Duration,  Termination. — The  spasm  recurs  when- 
ever the  exciting  cause  is  present,  but  probably  with  less 
intensity.  Endolar3'ngeal  manipulation  may  at  first  cause  a 
violent  contraction,  but  only  a  slight  feeling  of  constriction 
the  second  or  third  time. 

The  duration  of  the  glottic  spasm  is  generally  short,  if  it 
is  violent  ;  but,  if  the  air  still  penetrates  the  air  tract, 
whistling  respiration  may  be  protracted  for  several  minutes, 
even  for  more  than  an  hour. 

In  the  case  of  a  foreign  body  the  crisis  occurs  at  each 
displacement.  This  is  a  characteristic  sign,  on  which  the 
author  dwells  later  on.  If  apnœa  is  complete,  asphyxia  may 
result.  The  spasm  generally  stops  at  this  stage,  and  the 
patient  is  then  able  to  breathe  normally,  unless  he  succumbs 
to  heart  failure.  This  fatal  termination  is  observed  specially 
in  people  affected  with  cardiac  disease  or  aneurismal  dilata- 
tion, in  whom  spasm  causes  rupture. 

Prognosis  is  based  on  the  foregoing  discussion,  and  is 
benign  in  most  cases. 

Diagnosis  is  easy.  The  history,  with  examination  of  the 
larynx,  generally  permits  the  cause  of  the  lesion  to  be  recog- 
nized, and  consequently  suggests  the  appropriate  remedy. 

Treatment. — The  initial  treatment  should  be  prophylactic, 
and  consist  in  keeping  the  patient  away  from  the  causes 
capable  of  producing  spasmodic  laryngitis.     Thus,  the   in- 


302  DISEASES  OF  THE  PHARYXX  AXD  LARYNX 

flammatory  or  œdematous  onsets  should  be  attended  to. 
Tumours  or  foreign  bodies,  if  they  exist,  must  be  removed. 
Should  the  spasm  be  the  result  of  direct  applications  or 
irritating  inhalations,  the  laryngeal  mucosa  should  be 
gradually  accustomed  to  them. 

These  contractions  are  less  frequent  and  intense  if  the 
vocal  mucosa  has  been  ansesthetized  with  a  solution  of 
h}-drochloride  of  cocaine  (i  :  15  or  i  :  loj.  In  every  case, 
before  painting  the  larynx  for  the  first  time,  the  practitioner 
should  assure  himself  that  nasal  respiration  is  normal.  If 
it  is  not,  the  nasal  mucosa  should  unhesitatingly  be  painted 
with  a  solution  of  adrenalin  (5  :  i,oooj,  or  even  with  an 
adrenalized  and  slightly  cocainized  solution.  Under  the 
influence  of  this  application,  the  Schneiderian  membrane 
undergoes  a  considerable  retraction,  which  renders  nasal 
respiration  freer.  By  this  method  spasm  is  prevented,  or 
at  least  decreased. 

Treatment  of  the  onset  itself  should  consist  in  preventing 
the  patient  struggling  to  get  air  and  widely  opening  his  month. 
He  should  be  asked  to  retain  his  breath  for  a  moment  or  two,  and 
resume  breathing  gently  through  the  nose. 

If  the  spasm  is  due  to  the  forced  depression  of  the  tongue, 
care  must  be  taken  to  depress  only  the  anterior  third  of  this 
organ  gently  and  slowly,  in  order  to  give  confidence  to  the 
patient,  who  should  be  asked  to  make  an  expiration  while 
emitting  the  sound  '  ah.'  As  far  as  possible  the  tongue- 
depressor  should  not  be  introduced  during  inspiration,  and, 
above  all,  the  base  of  the  tongue  should  not  be  thrust  back 
on  the  laryngeal  orifice,  as  the  epiglottis,  being  kept  down, 
might  produce  the  crisis. 

Spasms  of  Peripheral  Origin. — Those  spasms  result 
from  the  irritation  of  the  pneumogastrics,  or  of  their  re- 
current branches.  This  is,  as  it  were,  the  first  stage  of 
recurrent  paralysis,  and  is  therefore  due  to  the  same  causes 
— hypertrophy  of  the  lateral  lobes  of  the  thyroid  body, 
malignant  neoplasms  of  the  trachea  or  of  the  superior  third 
of  the  air  tract,  aneurismal  tumours  of  the  aorta  (left  re- 
current;, or  of  the  subclavian  (right  recurrent,),  indurations 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     303 

of  the  apex  of  the  right  lung,  certain  abscesses  of  the  neck, 
wounds  in  that  region,  and,  finally  and  specially,  transitory 
or  chronic  hypertrophy  of  the  peritracheal  glands.  This 
adenopathy  is  one  of  the  most  frequent  causes  of  irrita- 
tion of  the  laryngeal  or  pneumogastric  nerves  in  children,  as 
well  as  in  adults. 

The  spasmodic  disturbance  occurs  when  there  is  irritation 
of  the  nerve  filaments,  without  abolition  of  their  function. 
In  the  latter  case  unilateral  or  double  paralysis  would 
occur. 

Symptoms. — At  the  outset,  when  the  excitation  is  slight, 
the  patient  complains  of  a  mere  tickling  sensation  in  the 
pharyngeal  cavity,  which  produces  coughing. 

The  cough  is  dry  and  spasmodic  in  nature.  Later,  it 
becomes  more  like  whooping-cough,  is  permanent,  and  often 
even  paralysis  of  one  of  the  vocal  cords  is  the  consequence 
of  an  aggravation  occurring  on  the  course  of  the  nerve. 

An  important  feature  of  those  spasms  is  that  they  appear, 
diminish,  and  even  cease  in  certain  positions  of  the  head  or 
neck.  This  is  noticed,  specially  in  tumours  of  this  region, 
even  in  cases  of  adenopathy. 

Laryngoscopic  examination  is  usually  negative.  Slight 
redness  is  observed  on  the  posterior  portion  of  the  cords  and 
on  the  interarytenoid  region,  when  coughing  is  obstinate  or 
spasm  frequent. 

Course,  Duration,  Termination. — The  course  of  this  neu- 
rosis varies  with  its  cause.  If  it  is  of  neoplastic  origin,  the 
spasmodic  cough  at  the  outset  is  usually  replaced  by  the 
loss  of  movement  of  the  vocal  cord,  or  cords  corresponding 
to  the  compressed  recurrent.  In  cases  of  adenopathy,  goitre, 
or  pulmonary  consolidation,  the  nervous  irritation  varies 
according  to  the  treatment,  or  spontaneously. 

Prognosis  depends  on  the  cause  of  the  muscular  disturb 
ance.     The   latter   is,   however,   seldom    intense   enough   to 
endanger  life  or  necessitate  surgical  intervention. 

Diagnosis  should  chiefly  consist  in  determining  the  primary 
cause  of  the  nerve  irritation.  This  is  not  always  easy  to 
accomplish,    as   the   methodical   examination   of  the   organs 


304  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

lying  along  the  course  of  the  pneumogastric  or  the  recurrent 
often  may  not  allow  of  the  nature  of  the  irritation  being 
recognized.     Radioscopy  or  radiography  is  helpful. 

Treatment.— Once  the  cause  of  the  lesion  is  recognized,  it 
should  first  of  all  be  attended  to.  In  doubtful  cases  iodide 
of  potassium  or  of  sodium  should  be  prescribed  in  variable 
doses,  according  to  the  tolerance  of  the  patient.  Counter- 
irritants  (tincture  of  iodine,  blisters,  methyl  chloride,  igni- 
puncture,  etc.)  may  be  applied  to  the  course  of  the  nerve. 
If  they  fail,  morphia,  chloral  (alone  or  associated  with 
bromide  of  potassium),  will  relieve  the  patient  for  some 
time. 

Sprays  of  hydrochloride  of  cocaine,  along  with  bromide  or 
antipyrin,  are  also  excellent  applications.  Salicylate  of  soda 
in  some  rheumatic  people  gives  good  results.  Finally,  as  the 
disease  progresses,  irritation  of  the  nerve  is  replaced  by  the 
abolition  of  its  function,  with  atrophy. 

Spasms  of  Central  Origin. — -Those  spasms  are  now 
better  known.  According  to  some  authors  (Krause),  spasm 
of  the  laryngeal  muscles  is  observed  in  certain  affections  of 
the  nervous  centres.  It  may  be  consequent  on  spinal 
syphilis,  cerebral  tumours  or  haemorrhages,  saturnine 
paralysis,  epilepsy,  pseudo  -  bulbar  paralysis,  progressive 
general  paralysis,  sclerosis  en  plaque,  railway  -  spine,  and 
tabes.  In  most  of  those  cases  there  exist  either  disturbances 
of  sensation  or  paralysis  of  the  laryngeal  muscles,  sometimes 
even  permanent  contraction,  but  true  spasmodic  crises  are 
observed  only  in  locomotor  ataxy. 

Symptoms. — The  author  does  not  intend  to  describe  here 
the  symptoms  of  tabes  in  general,  but  only  the  spasmodic 
disturbances  observed  either  in  the  course  of  or  premoni- 
tory to  this  affection.  We  may  divide  them  into  three  groups, 
according  to  their  intensity  :  (i)  onsets  of  simple  spasmodic 
cough  ;  (2)  onsets  of  choking  with  loss  of  consciousness  ; 
(3)  apoplectic  form,  with  asphyxia. 

I.  Onsets  of  Spasmodic  Cough. — -This  is  the  slight  form  of  the 
attack.  The  patient  experiences  in  the  pharyngeal  cavity  a 
titillating  or  a  smarting  pain  that  causes  fits  of  convulsive 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     505 

coughing  of  short  duration,  with  whistling  respiration.  In  a 
few  seconds  the  face  becomes  cyanosed,  the  patient  restless 
and  agitated,  and  suddenly  the  crisis  stops,  to  recur  three  or 
four  times  daily.  In  a  case  recorded  b}-  ^Slunschina  this 
crisis  was  accompanied  by  eructations  and  cardiac  disturb- 
ances (asystole). 

2.  Choking  Spasms. — -At  this  stage  the  spasm  is  sufficiently 
violent  to  occasion  complete  loss  of  consciousness,  with  or 
without  epileptiform  movements.  The  initial  symptom  is  a 
sensation  of  burning  in  the  throat  or  of  constriction,  then 
follow  a  sudden  contraction  and  adduction  of  the  cords  ; 
respiration  becomes  stridulous;  the  patient  becomes  pale, 
even  blue  and  cyanosed  (Krishaber).  His  face  is  flushed 
and  swollen.  Then  he  loses  consciousness,  but  yet  has  time 
to  fall  gently.  This  state  lasts  for  several  minutes,  and  is 
accompanied  by  convulsive  movements  of  the  limbs.  The 
pulse  is  rapid.  Then  the  spasm  suddenly  ceases,  respiration 
is  restored,  and  the  patient  becomes  conscious  again,  till  a 
new  crisis  occurs,  which  may  appear  on  the  least  cause. 

3.  Apoplectic  Spasms. — In  those  cases  the  patient,  seized  all 
of  a  sudden  by  a  true  sensation  of  strangulation,  collapses 
with  all  the  phenomena  of  cerebral  congestion.  The  face 
becomes  cyanosed  and  puffed,  the  eyes  project,  apnœa  is 
almost  complete.  The  pulse,  although  regular,  is  weakened 
and  accelerated.  Epileptiform  convulsions  accompany  this 
violent  crisis,  which  may  be  fatal,  unless  surgical  intervention 
is  rapidly  afforded. 

Usually  the  spasm  ceases  as  suddenly  as  it  appeared. 
The  characteristic  of  these  affections  is  its  sudden  appear- 
ance, often  without  any  apparent  immediate  cause.  In 
those  patients  a  diminution,  or  even  complete  abolition, 
of  sensibility  in  the  phar3'ngeal  cavity  is  frequently  observed. 
Laryngoscopic  examination  made  between  attacks  furnishes, 
as  a  rule,  negative  results  ;  but  in  some  patients  paralysis 
or  transitory  contracture  of  one  vocal  cord  has  been 
observed. 

Course— Duration. — Laryngeal  manifestations  may  appear 
at  the  premonitory  period  of  the  tabes  (pre-ataxic  period),  or 

20 


3o6  DISEASES  OF  THE  PHARYXX  AXD  LARYNX 

when  the  affection  is  clearlv  confirmed.  Those  prodromic 
phenomena  sometimes  precede  by  several  years  the  other 
symptoms  of  locomotor  ataxia.  In  many  cases  the  laryngeal 
crisis  has  been  the  means  of  the  diagnosis  of  this  disease. 

The  attacks  are  usually  slight  at  the  beginning,  and 
may  pass  unperceived  until  the  disease  has  reached  an 
advanced  stage.  The  course  of  the  affection  is  not  ahvavs 
progressive,,  for  the  patient  may  pass  abruptly  from  the  first 
to  the  third  stage,  just  as  the  onset  may  occur  several  times 
in  the  twenty-four  hours,  or  leave  the  patient  undisturbed 
for  several  days  or  even  months,  and  appear  afterwards  on 
the  slightest  cause. 

Prognosis. — Laryngeal  crises  of  themselves  constitute  a 
serious  complication  of  tabes,  in  so  far  as  they  are  an 
aggravation  of  the  general  affection. 

Pathological  Anatomy. — On  autopsy,  there  are  generallv 
found  bulbar  lesions  or  alterations  of  the  roots  of  the  pneumo- 
gastrics,  of  the  spinal  accessories  or  the  nerve  trunks,  which 
are  reduced  to  slender  filaments.  Laryngeal  crises  have  been 
attributed  by  several  authors  ''Gieson)  to  neuritis  of  the  nerve 
trunks,  rather  than  to  the  central  lesions  seen  on  autopsy. 

Pathological  modifications  of  the  laryngeal  membrane  are 
more  the  result  than  the  cause  of  spasm. 

Diagnosis. — When  spasm  occurs  at  the  pre-ataxic  period, 
diagnosis  may  be  difficult,  especially  if  the  crisis  is  slight. 
Manifest  analogies  are  then  presented,  either  with  spasms  due 
to  peripheral  irritation,  or  with  reflex  spasms.  Diagnosis 
can  be  established  by  a  careful  examination  of  the  patient, 
eliminating  all  causes  of  compression  of  nen,-e  filaments  and 
by  examination  of  the  various  organs  capable  of  producing  a 
reflex  spasm,  more  especially  the  nasal  fossae,  and  sometimes 
by  seeking  for  the  different  signs  of  tabes  or  other  nerve 
lesion. 

If  laryngoscopic  examination  reveals  the  existence  of  a 
paretic  or  paralytic  vocal  aftection  without  any  appreciable 
cause  of  compression,  a  central  lesion  should  be  looked  for. 
AVhen  the  apoplectic  form,  with  loss  of  consciousness,  occurs, 
it  is  almost  certain  to  be  connected  with  locomotor  ataxia. 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     307 

Treatment. — As  the  laryngeal  crisis  depends  on  central 
disease,  the  latter  should  first  of  all  be  attended  to.  If  the 
crisis  endangers  life,  tracheotomy  should  be  performed. 
During  the  onset  of  suffocation  artificial  respiration,  inhala- 
tions of  ether  or  of  chloroform,  or  intubation  of  the  larynx, 
will  prevent  asphyxia. 

Reflex  Spasms. 

These  include  certain  spasmodic  disturbances  of  the  laryn- 
geal muscles,  consequent  on  lesions  of  more  or  less  distant 
organs. 

Etiology. — Those  contractions  are  commonly  met  with  in 
connection  with  irritation  or  lesions  connected  with  the  ear, 
stomach,  uterus,  and  particularly  the  nasal  fossae. 

The  genital  or  uterine  cough  (dry  and  spasmodic)  is  observed 
after  sexual  intercourse,  normal  or  excessive,  after  or  during 
menstruation,  and  without  any  lesion  being  found  in  the  uterus. 
The  ligature  of  the  pedicle  in  hj^sterectomy  sometimes  causes 
violent  onsets  of  laryngeal  spasm.  The  various  affections  of 
the  cervix  uteri,  or  of  the  uterus  itself,  and  especially  any 
abnormal  position  of  the  latter  (anteversion,  retroversion,  etc.), 
may  also  produce  laryngeal  spasm.  It  usually  occurs  under 
the  influence  of  mental  excitation  in  predisposed  subjects, 
more  particularly  in  women.  Fits  of  spasmodic  coughing, 
and  even  of  suffocation,  sometimes  take  place  on  the  intro- 
duction of  an  aural  speculum,  or  on  probing  the  auditory 
meatus.  A  similar  effect  may  be  produced  by  the  following 
lesions  :  hypertrophy,  with  or  without  septal  deviation,  or 
with  spur  formation  pressing  on  the  swollen  mucosa  ;  lesions 
in  the  naso-phar3mgeal  cavity  ;  polypoid  degeneration  ;  true 
polypi  ;  or  other  irritation.  Some  authors  think,  that  dis- 
turbances of  the  stomach,  intestines  (Secchi),  uterus,  or 
genital  organs,  produce  reflex  cough  or  spasm  through  the 
Schneiderian  mucous  membrane. 

These  phenomena  appear  in  nervous  or  hysterical  subjects. 
The  immediate  causes  of  the  spasm  are  extremely  variable. 

Symptoms. — This  spasm  in  slight  forms  consists  simply  in 
a  fit  of  dry  v/hooping-like  cough,  analogous  to  that  observed 

20 — 2 


3oS  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

in  spasm  of  central  origin,  without,  however,  producing 
suffocation.  At  other  times  a  violent  contraction  of  the  vocal 
cords  takes  place,  impeding  the  passage  of  the  air  through  the 
constricted  glottic  orifice  ;  cyanosis  occurs,  even  asphyxia, 
followed  in  some  cases  by  loss  of  consciousness. 

The  crisis  usually  begins  with  a  fit  of  violent  spasmodic 
coughing,  accompanied  by  respiratory  inconvenience  ;  whereas 
at  other  times  the  glottic  constriction  is  abrupt,  rapid,  and 
grave  enough  to  necessitate  the  opening  of  the  air  tract. 

Onsets  occur  during  the  day  or  night,  and  often  without 
apparent  cause.  It  is  probable,  that  during  sleep  the  nasal 
congestion  becomes  more  and  more  pronounced,  according 
to  the  position  of  the  patient,  and  gives  rise  to  the  crisis.  In 
patients  affected  with  deviation  of  the  septum,  with  a  posterior 
spur,  the  lateral  decubitus  determines  the  swelling  of  the 
pituitary  membrane  ;  the  latter,  then,  coming  in  contact  with 
the  projecting  part  of  the  septum,  produces  the  reflex. 

The  contraction  is  sometimes  confined  to  the  phonator}' 
muscles,  thus  causing  true  phonic  spasm  (Heryng,  Brébion). 

On  examination,  the  larynx  appears  quite  normal.  After 
the  crisis  a  more  or  less  pronounced  hyperaemia  of  the  vocal 
mucosa  ma}-  be  observed,  but  it  is  rather  a  consequence  than 
the  cause  of  the  attack. 

Course,  Duration,  Terviination. — Reflex  spasms  take  place 
under  the  influence  of  a  direct  or  an  indirect  excitation  of 
the  irritable  area. 

The  onsets  occur  either  daily  or  at  more  or  less  distant 
intervals.  The  course  and  duration  are  very  irregular. 
When  diagnosis  has  been  made  and  rational  treatment 
applied,  a  cure  generally  results. 

Prognosis  depends  on  the  cause,  the  intensity  of  the  crisis, 
and  the  rapidity  of  the  diagnosis.  Tracheotomy  ma}-  be 
necessary,  but  only  in  exceptional  cases,  as  asphyxia  causes 
the  contraction  to  cease,  and  permits  the  patient  to  breathe. 

Diagnosis. — It  is  important  to  ascertain  the  origin  of  the 
laryngeal  disturbances.  Accordingly,  it  is  necessary  carefully 
to  examine  the  various  organs  liable  to  occasion  the  crisis, 
more   particularly  the    nasal   fossae.     If  rhinoscopy   proves 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     309, 

negative,  the  naso-pharyngeal  cavity  should  be  inspected. 
To  confirm  in  doubtful  cases  the  diagnosis,  a  cocainized 
solution,  with  or  without  adrenalin,  should  be  applied  to  the 
nasal  mucosa.  If  the  spasmodic  crisis  diminishes  in  intensity 
and  frequency,  there  is  ground  for  suspecting,  that  the  pituitary 
membrane  is  the  source  of  the  disease. 

Treatment. — Once  diagnosis  is  made,  (i)  the  attack  should 
be  treated,  and  (2)  its  reappearance  prevented. 

In  the  former  case  the  nasal  fossœ  should  be  first  sprayed 
with  a  solution  of  hydrochloride  of  cocaine  (adrenalized). 
The  patient  should  be  requested  to  breathe  through  the  nose 
gently,  the  mouth  being  closed.  The  following  solution  may 
be  employed  as  a  spray,  or  for  painting  the  pituitary 
mucosa: 

I^  Hydrochloride  of  adrenalin 

(i  :  1,000)        ...  ...  5  drops  Rv 

Hydrochloride  of  cocaine  30  centigrammes       gr.  5 

Sterilized  water  ...  15  to  20  grammes  3iv  to  v 

Inhalations  of  warm  water,  to  which  a  few  drops  of  chloro- 
form are  added,  afford  good  results  (Sir  Morell  Mackenzie). 

In  grave  cases  sinapisms  may  be  applied  to  the  chest  or  to 
the  calves.  The  face  should  be  sprinkled  with  cold  water,  or, 
if  need  be,  whipped  with  a  soaked  towel.  If  asphyxia 
threatens,  artificial  respiration,  even  tracheotomy  or  intubation 
of  the  larynx,  should  be  performed. 

In  the  second  case  attention  should  be  paid  to  the  cause 
of  the  spasm.  The  hypertrophied  nasal  mucosa  should  be 
treated,  the  spurs  removed,  etc. 

A  general  antispasmodic  treatment  (valerianates,  bromides, 
physical  exercise,  douches,  or  lukewarm  baths)  should  be 
prescribed. 

Spasms  Associated  with  a  General  Neurosis  : 

Nervous  Cough — Laryngeal  Chorea. 
Under    this    designation    are    comprised    spasmodic   phe- 
nomena observed  during  the  course  of  a  general  neurosis. 
This   condition  has  been   specially  studied  by  Massei   in 


3IO  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

1878,  and  in  the  following  year  by  Schrotter  under  the  name 
of  chorea  of  the  larynx. 

Nervous  cough  should,  however,  be  distinguished  from  the 
rarer  condition  of  laryngeal  chorea. 

(a)  Nervous  Cough. — By  this  we  mean  a  cough  which 
is  nois}^  and  of  a  more  or  less  metallic  character,  occurring 
apart  from  lesions  of  the  larynx,  lungs,  or  lar3mgeal  nerves. 

(b)  Chorea  of  the  Larynx. — This  condition  is  associated 
with  convulsions  of  the  muscles  of  the  face  or  of  the  limbs, 
resembling  chorea. 

Etiology. — Those  diseases  are  generally  due  to  hysteria  or 
to  an  exaggerated  nervous  irritability.  They  occur  in  w^omen 
affected  with  vaginal  disturbances,  or  in  cases  of  profound 
chlorosis  or  anœmia.  Fear  or  excitement  are  additional 
causes.  This  affection  is  specially  observed  in  girls  from 
sixteen  to  twenty  years  of  age. 

Symptoms. — Choreic  cough  is  characterized  by  its  being 
very  abrupt,  sudden,  and  noisy,  and  occurs  (Gottstein)  either 
paroxysmally  or  in  a  rhythmic  continuous  form. 

The  cough  and  choreic  movements  may  alternate. 

Nervous  cough  is  dry  and  rapid;  that  of  chorea  is  less 
frequent,  and  the  fits  cease  during  sleep.  Finally,  choreic 
disturbances  only  occur  during  a  physiological  action — viz., 
singing.  Laryngoscopic  examination  is  negative,  apart  from 
an  occasional  redness  of  the  mucosa  or  tremor  of  the  cords. 
During  the  crisis  the  arytenoids  are  observed  to  adduct 
abruptly,  and  the  cords  assume  the  phonatory  position. 

Diagnosis. — -The  important  point  of  the  diagnosis  is  to 
eliminate  lesions  capable  of  irritating  or  compressing  the 
pneumogastric  or  recurrent  lar3'ngeal  nerves.  Examination 
of  the  nasal  fossse  sometimes  shows,  that  the  phenomena 
observed  are  due  to  a  reflex  origin. 

Course,  Duration,  Termination. —  In  hysterical  patients 
laryngeal  spasm  may  disappear  for  years  without  leaving  the 
least  trace.  It  often  alternates  with  spasmodic  disturbances 
of  other  regions.  When  due  to  the  lesion  of  another  organ, 
it  generally  vanishes,  w^hen  the  latter  has  been  cured.  Vocal 
chorea  may  persist  for  years. 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     311 

Prognosis  is,  on  the  whole,  good,  except  in  some  cases, 
where  the  patients  cannot  enjoy  sleep  or  rest. 

Treatment  consists  in  the  administration  of  tonics.  In 
chronic  nervous  cough  antispasmodics  may  be  used  bene- 
ficially. Sometimes  quinine,  arsenic,  and  other  tonics  are 
to  be  preferred.  Douches  and  protracted  lukewarm  baths 
will  counteract  the  nervous  condition  of  the  patient.  Travel 
and  amusement  are  of  benefit.  Locally,  cocainized  sprays, 
or  even  brushing  the  mucosa  of  the  larynx  or  the  pharyngeal 
cavity  with  ansesthetizing  solutions,  and  electrical  treatment 
with  massage,  should  be  prescribed.  Methodical  vocal 
exercise  is  also  of  advantage. 

Laryngeal  Vertigo. 

Etiology. — This  affection  is  characterized  by  giddiness, 
accompanied  by  loss  of  consciousness,  and  occurs  in  lesions 
of  the  respiratory  organs,  especially  spasmodic  bronchitis, 
polypi  of  the  larynx,  tabes,  or  even  independently. 

It  is  probably  due  to  the  influence  of  cold,  sudden  changes 
of  temperature,  emotions,  irritating  vapours,  alcoholic  bever- 
ages, but  mainly  to  a  neurotic  temperament. 

Symptoms — Pathogeny. — The  onset  is  usually  preceded  by 
titillation,  a  sensation  of  burning,  or  even  by  a  feeling  of 
a  foreign  body  in  the  larynx. 

Shortly  afterwards  fits  of  whooping-like  cough  take  place, 
followed  by  loss  of  consciousness.  The  vertigo  is  occasion- 
ally slight,  and  resembles  the  sensation  due  to  a  blow  on  the 
head.  At  other  times  it  appears  as  a  spasmodic  cough,  with 
dyspnoea,  and  a  vague  sensation  of  giddiness,  without  loss  of 
consciousness. 

The  cause  of  those  disturbances  is  obscure.  We  may 
assume  with  Weill,  that  the  larynx  is  the  origin  of  a  series 
of  irritations,  which  may  extend  to  the  central  nervous 
system,  and  suspend  the  cerebro-spinal  activity,  or,  on  the 
contrary,  reinforce  it. 

Course — Duration. — The  course  of  laryngeal  vertigo  is 
exceedingly  variable,  and  depends  on  the  cause  of  the 
lesion.     It    may   alternate  with    the    crisis   of  asthma,   and 


312  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

then  occur  at  more  or  less  distant  intervals.  In  other  cases 
the  crises  are  frequent,  appearing  several  times  daily,  and 
are  of  short  duration.  The  patient  has  an  attack  of  giddi- 
ness or  of  a  temporary  loss  of  consciousness,  which  compels 
him  to  stop  and  support  himself.     He  seldom  falls. 

Diagnosis. — It  is  extremely  difficult  to  differentiate  lar^m- 
geal  vertigo  from  reflex  spasm.  Diagnosis  is  founded  on 
the  presence  or  absence  of  nasal  lesions. 

Treatment. — The  general  nervous  condition  of  the  patient 
should  be  treated  with  antispasmodics.  Sedative  sprays 
should  afterwards  be  applied  to  the  laryngeal  mucosa,  or  the 
parts  brushed  with  the  following  : 

I^  Hydrochloride  of  cocaine  60  cgms.  to  i  gramme    gr.  g  to  15 
Antipyrin    and    bromide 

of  potassium          ...  ââ    4  grammes    ââ  gr.  60 

Glycerine        ...              ...  40        „                      5ix 

Tincture  of  eucalyptus  ...  10        ,,                  Tl\clx 

Water              ...             -...  450        ,,                    sxvi 

This  should  be  employed  once  or  twice  daily  for  three  to 
hve  minutes  with  a  steam  spray. 

Should  congestion  of  the  vocal  mucosa  appear  to  be  the 
cause  of  the  attack,  the  following  spray  may  be  pre- 
scribed : 

^  Hydrochloride  of  cocaine      60  cgms.  to  i  gramme      gr.  g 

to  15 

Hydrochloride  of  adrenalin 

(1:1,000)         ...  3  to  5  grammes  ll^^xlv  to  Ixxv 

Bromide  of  potassium  ...       5         ,,  ë^-75 

Glycerine  )  --    -^  f  ^^^ 

■^  .  [  aa  50         „  J      .. 

Peppermmt  water j  ioxii 

Water       ...  ...  ...   400         „  sxiv 

In  pronounced  vocal  irritation,  chlorate  of  zinc  or 
nitrate  of  silver  (i  :  60  or  i  :  50  to  i  :  30)  produces  excellent 
results,  when  inflammatory  forms  of  the  laryngeal  mucosa 
exist. 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX 


Tumours  of  the  Larynx. 

Laryngeal  tumours  may  be  classified  into  two  groups  : 
(i)  those  constituting  an  affection  essentially  localized  in 
the  mucous  membrane,  or  (2)  those  appearing  as  infiltrated 
neoplasms  tending  to  invade  the  neighbouring  parts.  Those 
are  respectively  the  benign  or  the  malignant  tumours,  the 
former  being  described  as  polypi  of  the  larynx. 

Benign  Tumours  (Polypi  of  the  Larynx). 

Etiology. — The  causes  of  benign  neoplasms  of  the  vocal 
mucosa  are  most  complicated.  Laryngeal  polypi  result  from 
acute  or  subacute  inflammation  of  the  vocal  cords  (Sir  ]\Iorell 
Mackenzie),  though  sometimes  the  reverse  holds  good.  It  is 
often  impossible  to  say  whether  the  chronic  catarrh  accom- 
panying these  benign  tumours  is  primary  or  secondary, 
though  the  latter  is  the  more  probable. 

Some  authors  have  thought  that  the  nodal  points  of  the 
vocal  cords  were  most  predisposed  to  fibroma  (Klebs  and 
Schnitzler).  Certain  professions  (singing,  teaching,  speaking, 
etc.)  predispose  to  laryngeal  polypi,  which  generally  occur 
about  adolescent  and  adult  age  (twenty  to  fifty).  Since 
laryngoscopy  has  become  more  general,  benign  neoplasms 
of  the  larynx  are  more  frequently  observed  than  formerly. 

Laryngeal  polypi  appear  to  be  more  common  in  men  than 
in  women  (Schwartz).  Local  irritation  plays  a  part  in  their 
production,  heredity  being  of  little  account. 

Symptoms. — Benign  tumours  of  the  larynx  may  give  rise  to 
different  functional  disturbances,  varying  according  to  the 
site  and  nature  of  the  polypi  (sessile  or  pedunculated,  old 
or  recent,  small  or  bulky),  and  according  to  the  rapidity  or 
slowness  of  their  growth. 

Voice. — If  the  polypus  is  situate  on  one  of  the  vocal 
cords,  as  is  most  frequently  the  case,  the  first  disturbances 
are  those  of  phonation. 

Those    vocal    alterations    sometimes    pass     unperceived. 


314  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

Singers  have  at  the  commencement  a  difficulty  in  emitting 
shades  of  sound,  the  note  is  less  pure,  and  the  passing  from 
the  chest  voice  to  a  falsetto  is  less  easy.  Dysphonia, 
huskiness,  and  aphonia,  are  observed  in  some  cases.  The 
symptoms  are  more  or  less  pronounced,  depending  on 
whether  the  polypus  is  situate  at  the  level  of  the  anterior 
third,  on  the  free  edge  of  the  vocal  cord,  or  above  the 
latter. 

As  the  tumour  is  sessile  or  pedunculated,  the  voice  will 
be  altered  in  a  permanent  or  transitory  manner.  Indeed, 
when  the  polypus  has  a  sufficiently  long  pedicle,  it 
may  place  itself  either  above  or  below  the  glottic  lips, 
and  a  relatively  clear  voice  may  now  and  then  become 
normal. 

On  the  contrary,  it  may  happen  during  the  emission  of  a 
word  or  phrase,  that  the  voice  suddenly  becomes  husky,  or 
even  aphonic,  if  the  polypus  changes  its  place.  Some 
singers  possess  the  phenomenon  known  as  diphonia,  or 
double  voice. 

It  therefore  seems,  that  polypi  of  comparatively  small 
size,  situate  on  the  edge  of  the  vocal  cords  or  at  their 
angle,  may  produce  a  relatively  considerable  vocal  altera- 
tion, whereas  a  more  voluminous  pedunculated  tumour, 
situate  above  or  below  the  glottic  lips,  will  hardly  affect 
the  voice. 

When  the  polypi  are  situate  at  other  points,  the  functional 
symptoms  are  irregular.  If  the  interarytenoid  region  is 
affected,  the  voice  becomes  dull,  husky,  or  even  hoarse  ;  but 
the  voice  may  be  intact,  if  the  tumour  is  on  the  epiglottis  or 
the  aryepiglottic  folds. 

Vocal  disturbances  are  generally  more  pronounced  in 
children  than  in  adults,  the  least  pathological  projection 
preventing  the  vibration  of  the  cords. 

Diffuse  tumours  (papillomata)  produce  aphonia. 

Respiration. — Respiratory  difficulty  is  usually  absent.  It 
depends  on  the  site  and  dimension  of  the  neoplasm.  If  the 
neoplasm  is  very  large  and  grows  slowly,  it  may  acquire  an 
excessive  volume  without    causing    too    intense  respiratory 


DISEASES  AND  rRAUMATISMS  OF  THE  LARYNX     315 

disturbances.  The  glottic  orifice  is  almost  entirely  obstructed 
by  the  tumour,  before  dyspnoea  appears.  The  latter  some- 
times approaches  suffocation,  and  threatens  death  from 
asphyxia.  Wet  weather  increases  the  respiratory  difficulties, 
owing  to  the  hydroscopic  nature  of  the  polypi.  Inflamma- 
tion of  the  laryngeal  or  pituitary  mucosa  helps  to  intensify 
the  dyspnœa.  When  the  tumour  is  very  pedunculated,  the 
fits  of  suffocation  or  of  asphyxia  are  paroxysmal.  Generally 
speaking,  it  is  in  consequence  of  some  muscular  effort,  or  of 
the  accumulation  of  secretions  in  the  larynx,  that  dyspnceic 
disturbances  are  produced. 

Certain  positions  of  the  head  affect  respiration  (Fauvel, 
Poyet)  :  thus,  bending  forwards  facilitates  breathing,  while 
extending  it  backwards  hinders  the  entrance  of  air. 

In  the  case  of  children,  owing  to  the  narrowness  of  the 
glottic  orifice,  respiratory  disturbances  constitute  an  important 
symptom. 

Cough.- — Cough  is  rather  rare,  and  may  be  associated  with 
a  concomitant  affection  (catarrhal  laryngitis).  Occasionally 
pedunculated  polypi  may  lie  across  the  glottis  and  produce 
a  short  '  hem,'  but  that  is  exceptional,  for  the  laryngeal 
mucosa  becomes  accustomed  to  continual  titillation,  and 
this  reflex  disappears.  The  repeated  friction  may  so  dull 
tactile  sensibility,  as  to  facilitate  surgical  intervention  by  the 
natural  tract. 

When  cough  does  exist,  it  follows  the  modifications  of  the 
voice,  assuming  successively  its  husky,  raucous,  croupoid 
(children),  muffled  tone. 

Dysphagia. — Deglutition  is  only  affected,  when  the  tumour 
is  extra-laryngeal,  and  occupies  the  epiglottis  or  the  arytenoid 
region,  and  has  acquired  sufficient  bulk,  to  obstruct  the 
oesophageal  entrance  at  the  moment  the  bolus  reaches  it. 

Pain. — -Pain  never  exists  in  benign  tumours  of  the  larynx. 
If  the  polypus  is  bulky  and  situate  outside  the  vocal  organ, 
there  is  only  a  feeling  of  uneasiness  or  of  a  foreign  body  in 
the  pharyngeal  cavity. 

Expectoration  is  usually  absent.  Sometimes  fragments  of 
neoplastic  tissue  (papillomata)  are  important  in  diagnosing 


3i6  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

the  disease,  though  they  cannot  indicate  the  site  and  size 
of  the  tumour. 

Objective  Symptoms. — The  physical  signs  are  ahvays  fur- 
nished by  direct  inspection  of  the  organ.  This  should  be 
made  by  strongly  depressing  the  tongue  (especially  in  the 
case  of  children)  with  Escat's  or  Kirstein's  depressor,  or 
recourse  may  preferably  be  made  to  the  laryngoscope.  To 
complete  the  diagnosis,  palpation  with  the  help  of  the  probe 
should  be  employed,  after  the  vocal  mucosas  are  anaesthetized 
with  cocaine. 

Site. — Benign  tumours  of  the  larynx  have  a  noticeable 
predilection  for  the  vocal  cords.  They  are  relatively  rare 
in  the  ventricles,  and  quite  exceptional  elsewhere.  Simi- 
larly, subglottic  tumours  are  less  common. 


/-v, 


Fig.   151. — Polypus  of  the  Angle  Fig.   152. — Papilloma  of  the 

OF  THE  Vocal  Cords.  Right  Vocal  Cord. 


Benign  tumours  may  be  divided  into  papillomata,  cysts, 
fibromata,  myxomata,  adenomata,  lipomata,  angiomata, 
enchondromata,  and  mixed  tumours. 

The  etiology  and  symptomatology  of  laryngeal  polypi  in 
general  is  applicable  to  those  various  morbid  productions. 

Papillomata  are  the  tumours  most  frequently  met  with 
in  the  larynx. 

Site. — Papillomata  are  situate  on  the  vocal  cords,  usually  on 
their  anterior  or  middle  third.  They  are  sessile  or  peduncu- 
lated, generally  defined  and  single,  but  several  distinct 
tumours  have  been  observed.  Usually  symmetrical,  papil- 
lomata have  a  rosy-grey  appearance,  with  a  smooth  glossy 
surface,  and  become  reddish  after  coughing,  when  they  have 
been  exposed  to  repeated  friction  or  unsuccessful  operation. 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     317 

They  are  of  rounded  form,  and  may  reach  a  size  from 
that  of  a  millet-seed  to  a  pea,  and  even  larger.  They 
are  often  muriform,  composed  of  small  granular  projections 
of  the  size  of  a  pinhead,  and  are  then  of  a  paler,  rosy,  almost 
yellowish  hue,  and  their  surface  is,  as  it  were,  bristling  with 
wart}'  projections.  These  papillomata  are  usually  diffuse, 
reach  the  volume  of  a  horse-chestnut,  and  are  comparable 


Fig.   153. — Diffuse  Papillomata  of  the  Laf.yxx. 

to  a  large  wart.  They  are  formed  of  a  central  projecting 
portion,  from  which  granulations  are  diffused,  which  give  them 
the  appearance  of  a  small  cauliflower.  They  are  sometimes 
congenital,  and  are  fairly  frequent  in  children.  These  benign 
tumours  occupy  the  cords,  the  ventricular  bands,  the  ary- 
epiglottic  ligaments,  the  arytenoids,  the  posterior  surface  of 
the  epiglottis,  and  sometimes  even  the  subglottic  region. 


Fig.   154. — Papilloma  of  the  Right  Cord  in  a  Child  of  Eight  Years. 
(After  Morell  Mackenzie.) 

The  papillomata  are  of  a  flabby  consistency,  and  swing  to 
and  fro  with  the  respiratory  movements.  At  other  times 
they  have  a  horny  appearance,  especially  in  certain  old  men. 
In  these  latter  cases  they  may  become  malignant  (epithelioma). 
Prognosis  is  not,  however,  always  so  grave,  for  the  author 
has  observed  benign  horny  tumours  in  adults  above  forty- 
five  years  of  age. 


3i8 


DISEASES  OF  THE  PHARYNX  AND  LARYNX 


Cysts. — Voluminous  intralaryngeal  and  extralaryngeal 
cysts  may  be  always  considered  as  rare.  On  the  contrary, 
small  cystic  dilatations  of  the  cords  are  relatively  frequent, 
and  have  been  often  confused  with  papillomata,  small  angio- 
mata,  or  adenomata. 

Extralaryngeal    cysts  occupy  the   lingual    surface  or  the 


Fig.  155. — Cyst  on  the  Free  Border  and  the  Lingual  and  Laryngeal 
Surfaces  of  the  Epiglottis  (Right  Side). 

edges  of  the  epiglottis.  They  are  the  most  voluminous,  and 
may  attain  the  size  of  an  almond.  They  are  smooth  and 
even  on  their  surface,  and  resemble  a  transparent  hemisphere. 
The  cyst  wall  is  of  a  pale  yellow  and  slightly  rosy  hue.  A 
delicate  vascular  arborescence  is  observed  on  the  surface  of 
the  cyst,  which  is  much  distended. 

These  tumours  occur  on  the  arytenoid  region,  the  ventri- 


FiG.   156. — Cyst  on  the  Lingual  Surface  of  the  Epiglottis. 


cular  bands,  or  on  the  ventricles,  their  contents  being  generally 
serous  or  colloid,  bloody  or  caseous  (Blanc).  In  the  latter 
case  they  may  be  confused  with  dermoid  cysts.  When  they 
are  seized  with  forceps  a  little  blood  escapes,  with  evacuation 
of  the  contents. 

Intralaryngeal  cysts  are  the   most   frequent,  and  vary  in 
size  from  a  pinhead  to  a  walnut,  their  volume  being  on  the 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     319 

whole  small.     They  are  often   situate   on  the  edge  of  the 
vocal  cords,  are  sessile,  and  are  of  a  greyish  or  yellowish 


Fig.  157. — Cyst  of  the  Free  Border  of  the  Right  Vocal  Cord. 

appearance,   and  under  a  good  light   may  even  sometimes 
resemble  a  small  transparent  vesicle. 


Fig.  158.— Cyst  projecting  from  the  Ventricle  of  Morgagni 
(Right  Side). 

Those  tumours  contain  a  caseous  substance,  thick  and  con- 
crete.    They  are  attached  to  the  vocal  cord  by  a  broad  base. 


Fig.   15g. — Cyst  of  the  Left 
Ventricular  Band. 


Fig.   160. — The  same  Larynx 
after  Operation. 


which  gradually  blends  with  the  healthy  parts.    They  are  hard 
to  the  touch  and  avoid  the  grasp  of  the  forceps,  which  renders 


320 


DISEASES  OF  THE  PHARYNX  AND  LARYNX 


their  extraction  as  difficult  as  some  very  sessile  fibro- 
mata. 

In  the  histological  examination  of  a  case  the  cyst  was 
lined  by  thick  stratified  pavemented  epithelium  (Nadal),  the 
desquamated  cavity  being  filled  by  the  epithelial  cells. 

When  the  cyst  is  voluminous,  it  resembles  a  very  tense 
envelope  filled  with  liquid.  It  becomes  rosy  or  even  red 
after  attempts  at  extraction  or  repeated  palpation,  owing  to 
interstitial  hœmorrhage.  The  structure  of  the  hmiting 
membrane  is  in  nowise  different  from  other  cystic  tumours. 


Fig.  i6i. — Congenital-  Intralaryngeal  Cyst  in  a  Child.     (Edis.) 

Laryngeal  cysts  should  be  considered  as  retention  tumours, 
developed  within  the  glands.  The  cavity  in  these  cates  is 
formed  at  the  expense  of  the  glandular  cul-de-sac  by  dilata- 
tion of  the  excretory  canal,  whose  orifice  is  obstructed  by 
external  pressure,  or  by  swelling  of  the  walls,  or  by  a  plug  of 
desiccated  mucus. 

Fibromata. — The  usual  site  of  those  neoplasms  is  the 
vocal  cord,  and  seldom  elsewhere.  Sometimes  interstitial 
fibromata  occupy  the  interarytenoid  region.  These  neoplasms 
are  usually  single  and  almost  never  pedunculated.  The  size 
(Massei)  varies  from  that  of  a  mustard-seed  to  a  haricot- 
bean.     They  are  formed  from   the    submucous  tissue,  and 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     321 

consist    of    connective     tissue     intermingled     with     elastic 
fibres. 

The  fibromata  are  regular,  unilobular,  generally  hemi- 
spherical, or  slightly  elongated  and  circumscribed.  They 
may  present  two  lobes,  specially  when  degeneration  occurs. 
Cases  of  fibromata  with  long   peduncles  have  been  noted. 


a  0 

Fig.   162. — Fibromata  of  the  Larynx.     (Morell  Mackenzie.) 

a,  Tumour,  probably  fibro-myxomatous  ;  b,  fibroma  of 
the  base  of  the  epiglottis. 

Their  colour  is  greyish  and  resembles  that  of  the  cords  in 
slight  catarrh.  They  firmly  adhere  to  the  parts  on  which 
they  are  inserted.  Their  fibrous  nature  can  be  demonstrated 
with  a  probe  or  by  the  forceps,  as  they  readily  escape  from 
the  grasp  of  the  latter. 

If  the  fibroma  is  on  one  of  the  vocal  cords,  inflammation  and 
desquamation  of  the  opposite  cord  usually  occur,  sometimes 


Fig.  163. — Fibroma  of  the  Free  Border  of  the  Vocal  Cord. 

(COUPARD.) 

even  with  loss  of  substance,  in  consequence  of  the  friction  on 
it  of  the  neoplasm.  This  is  a  regular  occurrence  in  the  case 
of  hard  tumours  situate  on  the  free  edge  of  the  vocal 
cords. 

Myxomata.  —  Those    tumours,    considered    rare,    when 
diagnosis  was  based  more  on  the  external  appearance  than 

21 


322  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

on  histological  examination,  are  usually  seen  in  the  larynx. 
They  are  soft,  rosy,  smooth  and  sessile,  and  generally 
unilobular.  They  sometimes  present  two  or  three  small 
projections,  recalling  œdematous  aryepiglottic  folds.  Besides 
this  gelatinoid  appearance,  they  are-  characterized  by  the 
existence  of  a  reticulated  mucous  tissue. 

Adenomata. — Those  are  very  rare,  and  accordingly  not 
well  known,  and  may  be  due  to  hypertrophy  of  the  laryngeal 
glands. 

Li  po mata. — As  there  is  no  adipose  tissue  in  the  larynx, 
lipoma  is  rarely  met  with  in  that  organ.  When  it  does 
occur,  it  is  usually  seated  on  the  epiglottis.      The  tumour 


^.CT'-^- 


FiG.   164. — Myxoma  of  the  Two  Vocal  Cords. 
(Drawn  from  Nature.) 

I,  Fringed  and  eroded  epiglottis  ;  2  and  3,  vocal  cords,  having 
the  appearance  of  two  soft  œdematous  mucous  polypi. 

exhibits  a  smooth,  shining  surface  of  a  light  rosy,  somewhat 
yellowish  colour,  and  is  of  a  soft,  elastic  consistency.  Its 
shape  is  frequently  irregular.  It  contains  fat  cells,  con- 
nected by  fibrous  connective  tissue,  and  partly  filled  with 
crystallized  margarine. 

Angiomata. — Those  are  equally  rare  in  the  larynx.  At 
first  sight  they  recall  cysts,  from  which  they  differ  by  their 
darker  coloration  and  the  presence  of  haemorrhages.  Their 
size  is  usually  that  of  a  currant.  Sometimes  angiomata  are 
more  voluminous  and  of  an  irregular  form.  Those  tumours 
must  not  be  confused  with  blood-cysts.  The  latter  are  much 
more  frequent,  and  have  a  smooth,  light  red  colour,  and 
when    the    cyst   wall    is    opened,   slight    haemorrhage   takes 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     323 

place,  usually^due  to  a  vascular  rupture  in  the  cyst  wall,  or  to 
the  pseudo-cystic  dilatation  of  a  laryngeal  polypus. 


Fig.  165. — Angiomatous  Tumour  of  the  Larynx  and  of  the  Base 
OF  THE  Tongue.     (From  Nature.) 

Enchondromata  generally  originate  in  the  exaggeration 
or  in  the  deviation  of  physiological  activity,  but  at  other  times 
they  have  a  pathological  origin  (tuberculosis,  syphilis).  Apart 
from  chronic  inflammation  of  the  vocal  mucosa  (tuberculosis), 
these  tumours  appear    when    the   larynx   becomes  ossified. 


Fig.   166. — Enchondroma. 


They  occupy  the  cricoid,  sometimes  the  thyroid,  and  very 
rarely  the  arytenoids.  Their  appearance  is  that  of  the 
mucosa,  which  covers  them,  and  which  may  remain  mobile. 
Although  sometimes  lobulated,  they  are  always  smooth  and 
even  on  their  surface. 

Enchondromata    are    sometimes    recognizable    from    the 

21  —  2 


324  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

external  deformity  produced  ;  the  thyroid  is  often  swollen  ; 
and,  if  the  neoplasm  is  seated  on  the  cricoid,  the  latter 
presents  an  irregular  tumour  projecting  into  the  larynx  or 
below  the  cords. 

The  prognosis  of  enchondromata  is  particularly  grave,  as 
they  may  on  account  of  their  bulk  produce  laryngeal 
stenosis.  Fortunately  their  course  is  slow,  and  they  are 
seldom  voluminous  enough  to  block  the  glottic  orifice. 
Owing  to  their  hardness,  they  generally  necessitate  thy- 
rotomy. 

Mixed  Tumours. — As  a  rule,  tumours  of  the  larynx  do 
not  present  the  well-defined  characters  above  referred  to, 
but  the  various  elements  are  combined,  and  constitute  fibro- 
myxomata,   angiomyxofibromata,    angiomyxomata,   fibrosar- 


FiG.   167. — Nodule  on  the  Free  Edge  of  the  Right  Vocal  Cord 
(Angiokeratoma). 

comata,  chondrofibromata,  angiokeratomata.  Sometimes 
cavities  are  observed  in  these  neoplasms,  containing  a 
serous,  colloid,  or  hsemorrhagic  fluid  (haemorrhagic  fibro- 
myxomata). 

Course. — The  course  of  the  benign  laryngeal  tumours  is 
generally  slow.  Apart  from  the  cysts,  angiomata,  etc.,  which 
develop  with  comparative  rapidity,  their  evolution  may  take 
from  fifteen  to  twenty  years.  Life  may  be  endangered  on 
account  of  their  volume. 

Termination  sometimes  takes  place  by  spontaneous  expul- 
sion (diffuse  papilloma),  or  by  rupture  of  the  cyst  wail.  This 
usually  occurs  during  a  violent  effort,  as  sneezing  or  spas- 
modic coughing.  In  rare  cases  the  tumours  terminate  in 
degeneration  or  ulceration  with  suppuration. 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     325 

Semon   has  established,   (i)  that    benign  tumours  of  the 
larynx  seldom  become  malignant  after  intralaryngeal  opera- 


FiG.   168. — Histological  Section  (Sabrazès). 

a,  Keratinized  zone  ;  b,  thickened  epithelium  ;  c,  cellulo-mucous  chorion 
hollowed  with  fissures;  d,  angiomatous  mass;  e,  fibrous  transformation 
of  the  angioma. 


Fig.   169, — Voluminous  Telangiectasic  Tumour,  occupying  the 
Interior  of  the  Larynx.     (After  Botey.  ) 


tions  ;   (2)  that  the  operation  has  no  influence  on  the  trans- 
formation, when  the  latter  does  occur. 


326  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

The  author  also  thinks,  that  a  careful  diagnosis  corrobo- 
rates the  above  opinion,  as  in  some  alleged  cases  the  tumour 
was  malignant  from  the  first. 

Diagnosis  of  laryngeal  polypi  is  generally  easy  once  the 
vocal  cords  have  been  freed  from  mucus.  In  the  case  of 
children,  owing  to  their  resistance  and  the  depression  of 
their  epiglottis,  it  may  be  necessary  to  use  Kirstein's  or 
Escat's  instruments. 

Once  the  neoplasm  has  been  seen,  its  nature  remains  to 
be  determined.  As  a  rule,  this  is  revealed  only  by  micro- 
scopic examination. 

Œdema  of  the  cords  sometimes  has  the  appearance  of 
a  myxoma  or  of  a  cystic  tumour,  but  serous  effusion  is 
always  accompanied  by  inflammatory  symptoms. 

Tuberculous  and  syphilitic  vegetations  are  distinguished 
by  characteristic  lesions,  and  cannot  be  mistaken  by  an 
expert  eye.  Pseudo-polypoid  forms  of  tuberculosis  are  recog- 
nized only  on  histological  examination. 

The  prognosis  of  benign  laryngeal  tumours  varies  accord- 
ing to  the  age  of  the  patient.  In  the  case  of  intractable 
children,  intervention  is  awkward  and  often  impossible,  and 
besides,  the  narrowness  of  the  glottic  orifice  increases  the 
danger,  when  the  polypi  become  bulky.  In  adults  the 
prognosis  is  good,  except  when  asphyxia  occurs  from  a 
voluminous  tumour  before  laryngoscopic  examination  has 
been  made. 

A  bulky  pedunculated  tumour  situate  on  the  ventricular 
bands  or  the  aryepiglottic  folds  may  fall  into  the  air  tract, 
and  cause  death  from  suffocation. 

Diffuse  papillomata  may  block  the  glottic  orifice  and 
necessitate  the  opening  of  the  trachea.  They  are  more 
difficult  to  remove  by  the  natural  tract  than  the  other 
pol3'pi,  and  may  also  recur.  Finally,  in  some  very  rare 
cases  they  may  develop  into  malignant  tumours.  Cysts  do 
not  recur,  probably  owing  to  the  fact  that  the  continuous 
movements  of  the  vocal  mucosa  do  not  allow  the  walls  to 
reunite.  Fibromata,  being  usually  sessile,  are  difficult  to 
extirpate  completely  ;    but   since  cocaine  has  been  used  in 


DISEASES  AND  TRAUMATISMS  OF  THE   LARYNX     327 

intralaryngeal  operations,  even  the  smallest  fibromata  can 
be  removed. 

The  prognosis  of  enchondromata  is  less  favourable,  as  they 
generally  necessitate  thyrotomy,  or  even  partial  laryngectomy, 
owing  to  their  extent. 

The  extirpation  of  angiomata  is  sometimes  accompanied 
by  serious  haemorrhages,  which  may  require  tracheotomy 
and  tracheal  plugging,  either  with  Trendelenburg's  canula,  or 
with  gauze  introduced  through  the  natural  tract.  Applica- 
tion of  adrenalin  renders  post-operative  hsemorrhage  rarer 
and  less  abundant. 

The  vocal  prognosis  is  usually  favourable.  Whenever  the 
operation  through  the  natural  tract  is  possible,  as  is  the 
rule,  the  voice  is  restored  to  its  normal  state.  The  removal 
of  a  fibroma  situate  on  the  free  edge  of  a  cord  may  leave  a 
certain  change  in  the  singing  voice,  especially  in  tenors  and 
soprani.  On  the  contrary,  a  practised  operator  may  remove 
the  neoplasms,  even  in  the  case  of  singers,  without  leaving 
any  trace  behind. 

Treatment . — Abstention  may  be  advised  in  the  case  of  small 
neoplasms  occupying  the  lingual  surface  of  the  epiglottis  or 
the  ventricular  bands  ;  but  the  treatment  is  so  simple 
that  all  tumours  of  the  larynx  should  be  removed,  especially 
if  they  interfere  with  phonation  or  respiration.  Two  methods 
can  be  employed  —  the  endolaryngeal  and  the  extra- 
laryngeal.  Since  local  anaesthesia  of  the  larynx  has  been 
adopted,  the  operation  through  the  natural  tract  is  so  easy, 
that  the  external  method  is  necessary  only  in  exceptional 
cases. 

I.  Endolaryngeal  Method. — If  the  patient  is  intelligent 
and  tractable,  the  removal  of  most  of  the  laryngeal  polypi 
per  vias  natîirales  is  painless,  almost  bloodless,  and  without 
danger. 

The  vocal  mucosa  is  anaesthetized  by  an  insufflation  of 
sugar  and  cocaine  (i  :  10),  or  by  an  instillation  of  a  solution 
of  cocaine  in  water  (i  :  10).  This  anaesthesia  is  completed 
by  repeated  paintings  (four,  five,  or  even  ten  times).  In 
certain   patients   it   is  necessary  to    use  solutions    at    1:5, 


328  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

to  which  may  be  added  a  few  drops  of   adrenahn  solution 
(i  :  i,oooj. 
The    Dractitioner,    if    ri,g;ht-handed,    takes   the    mirror    in 


01  ^ 


t^      'jr.      <£ 


c 


his  left  and  the  forceps  in  his  right,  and  requests  the  patient 
to  keep  hold  of  his  tongue  with  his  left  hand.  Guided  by 
the   larvne-eal    mirror  'and    under    good    light,   the   operator 


DISEASES  AXD  TRAUMATISMS  OF  THE  LARYXX     329 

directs  the  instrument  towards  the  tumour,  and  tries  to  seize 
it  without  injuring  the  subjacent  parts. 

The  instruments  employed  are  various.     It  may  be  said 


Fig.   171. 


-Moritz-Schmidt's  Instrument  for  Polypi  of  the  Larynx, 
THE  Blades  opening  in  all  Directions. 


that  each  operator  has  his  own  particular  forceps.  For  a 
long  time  in  France  Fauvel's  forceps,  on  the  model  of  which 
others  have  been  made,  was  used  almost  exclusivelv. 


Fig.   172. 


-Cutting  Forceps  of  Dr.  Ru.ault,  acting  Laterally  and 
FROM  Before  Backwards. 


Stoerck,  Schrotter,  Krause,  and  Héring  recommend  the 
employment  of  a  varied  series  ot  instruments  of  slighter 
structure,  a  tube  of  laryngeal  curvature,  in  which  slides  a 
rod,   which    carries    at    its    free    end  forceps,   small  spoons, 


330  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

guillotines,  snares,  or  even  curettes,  whose  form  and  direction 
vary  according  to  the  requirements  of  the  case. 


Fig.  173.  —  Forceps  for  Laryngeal  Polypi  (Fauvel),  with  Assorted 
Blades  (Shape,  Size,  Strength)  for  Children  and  Adults. 
(Mathieu.) 

Though    this    extreme    mobilit}'    of  the   extremity  of  the 
instrument  makes  it  very  delicate,  yet  the  steel  thread  rusts 


Fig.  174. — De  Mendoza's  Antero-posterior  Lary'ngeal  Cutting 

Forceps. 

in  its  sheath,  becomes  more  brittle,  and  may  snap  during  an 
operation,  and  fall  into  the  larynx.  Therein  lies  the  dis- 
advantage   of    those    complicated    instruments,    which    the 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     331 

author  has  long  abandoned.  Those  sliding  forceps  have  also 
the  drawback  of  re-entering  their  tube,  when  they  should 
grasp  the  neoplasm.  Practice  with  the  instrument  overcomes 
in  a  short  time  this  difficulty.    On  the  contrary,  the  handling 


Fig.  175. — Direction  of  the  Forceps  at  the  Moment  of  Extirpation 
OF  A  Polyp  of  the  Vocal  Cord.  . 


of  those  forceps  is  easy.  They  are  specially  useful  in  cases 
of  small  polypi  inserted  on  the  edge  of  the  vocal  cords  or  in 
their  anterior  angle.  Moritz-Schmidt's  forceps  is  also  very 
suitable  for  cases  of  that  kind.     In  France,  Ruault  has  also 


332  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

constructed  a  series  of  composite  forceps,  which  in  skilled 
hands  give  very  good  results,  especially  when  the  morbid 
productions  are  sessile,  fairly  large  (grain  of  wheat,  a  pea, 
etc.),  and  hard  in  structure. 

In  a  general  way,  the  author  is  of  opinion  that  instruments 
made  of  one  piece,  having  shapes  varying  somewhat  accord- 
ing to  situation  of  the  lesions,  should  successively  be  used  for 
operation  in  the  larynx.  De  Mendoza's  forceps  is  adapted 
specially  for  beginners  or  operators  but  slightly  acquainted 
with  endolaryngeal  interventions.  In  some  cases  preference 
is  given  to  the  curette,  which  is  mainly  used  for  small  papillo- 
mata  or  certain  muriform  tumours  of  the  re-entrant  angle  of 


Fig.   176. — DuNDAS  Grant's  Forceps. 

the  cords.  With  an  inadequate  point  d'appui  the  operation 
with  the  curette  is  not  so  easy  and  simple  as  it  at  first 
appears,  and,  as  a  rule,  is  not  so  satisfactory  as  extirpation. 

The  time  at  which  the  removal  is  to  be  made  varies 
according  to  the  form  and  nature  of  the  neoplasms  and  their 
mode  of  implantation.  It  is  thus  that  pedunculated  tumours 
should  be  removed  during  phonation,  and  small  sessile 
growths  on  the  edge  of  the  cord  during  inspiration. 

For  cysts  crushing  is  sufficient.  These  tumours  should 
be  operated  on  either  with  cutting  forceps,  in  order  to  remove 
a  part  of  the  cyst  wall,  if  they  are  voluminous,  or  with  a 
guarded  bistoury  or  the  galvanic  knife,  in  order  to  empty 
their  contents. 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     333 

In  some  cases  of  small,  hard,  and  sessile  tumours  the 
galvano-cautery  may  be  employed.  This  requires  a  practised 
hand. 

Electrolysis    is    almost    abandoned.     Its    application    is 


Fig.   177. — Series  of  Instruments  (Krause)  :  Various  Forceps. 

rather  difficult,  and  is  suitable  only  for  very  vascular  polypi 
(angiomata). 

The  endolaryngeal  method  may  also  be  employed  in  the 
case  of  voluminous  tumours  causing  continuous  dyspnoea 
and  even  fits  of  suffocation.     The  only  danger  to  be  feared 


Fig.  178. — Laryngeal  Polypotome. 


is  not  the  spasm,  but  rather  the  haemorrhage,  if  the  tumour 
contains  important  vessels,  or  if  it  is  in  the  process  of 
sarcomatous  degeneration. 

When   benign  tumours  of  the  larynx   are   removed,   the 


334 


DISEASES  OF  THE  PHARYNX  AND  LARYNX 


voice  as  a  rule  is  immediately  restored  to  its  normal  condi- 
tion. It  afterwards  becomes  husky  during  the  post-operative 
inflammation  (about  three  weeks). 

2.  Extr alary ngeal  Method. — This  may  sometimes  be  neces- 
sary, as  in  children  affected  with  voluminous  tumours  en- 
dangering life.    Similarly  certain  recurring  diffuse  papillomata 


Fig     179.  —  Mahu's    Laryngeal    Forceps. 
a,  Acting  from  below  upwards  ;  b,  laterally. 

yield  only  to  curetting  after  laryngo-lissure  ;  and  it  is 
indispensable  in  those  cases  that  the  patient  should  retain 
the  canula  for  several  months.  With  some  children  the 
protracted  use  of  the  tracheal  tube  is  sufficient  to  cure 
papillar}^  degenerations  of  the  larynx  without  the  necessity  of 
opening  and  curetting  that  organ.  Likewise  ankylosis  of  the 
jaws  and  certain  deformities  of  the  tongue  make  the  external 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     335 

method  obligatory.  Enchondromata  generally  necessitate 
opening  of  the  larynx.  Three  methods  of  procedure  may 
then  be  adopted  : 

1.  Thyrotomy  (laryngo-fissure),  or  vertical  division  of  the 
thyroid  cartilage  in  the  middle  line. 

2.  Transverse  subhyoid  laryngotomy,  or  division  of  the 
thyro-hyoid  membrane. 

3.  Subhyoid  laryngotomy,  or  division  of  the  crico-thyroid 
membrane. 

Nodular  Laryngitis. 

This  is  a  variety  of  circumscribed  hypertrophy  of  the  vocal 
mucosa,  generally  localized  in  the  anterior  or  in  the  posterior 
third  of  the  cords. 

Etiology. — Nodular  laryngitis,  known  as  singer's  nodules, 
nodular  hyperplasic  chorditis,  singer's  chorditis,  inflammatory 
nodule,  etc.,  is  observed  in  singers,  speakers,  teachers,  etc., 
abusing  their  voice,  and  is  more  frequent  in  women  and 
in  subjects  possessing  a  small  larynx  (soprani,  tenors).  Those 
localized  hypertrophies  are  also  common  in  children,  and 
in  this  case  they  often  persist  till  adolescence. 

Pathogeny. — This  disease  probably  originates  in  the  irrita- 
tion of  the  cords  due  to  exaggerated  and  continuous  efforts 
during  phonation  and  singing,  and  more  especially  to  dis- 
placement of  the  voice. 

If  the  nodules  occur  more  frequently  on  the  anterior  third 
of  the  cords,  it  is  owing  to  the  fact,  that  this  portion  of  the 
glottic  orifice  closes,  when  the  chest  voice  is  changed  into 
falsetto.  Besides,  in  the  case  of  hypersecretion  of  the  mucosa, 
mucus  always  gathers  on  the  anterior  part  of  the  cords  and 
on  their  free  edges,  forming  there  a  milky  secretion,  which 
vibrates  during  phonation  and  constitutes,  first,  an  irritation 
at  this  part,  followed  by  a  local  hyperplasia.  The  posterior 
part  is  less  often  affected,  because  the  ary-arytenoid  muscle 
relieves  the  cords  at  this  level. 

Sometimes  after  vocal  fatigue  small  projections  of  nodular 
appearance  are  observed.  They  are  consequent  on  a  muscular 
relaxation  localized  at  the  junction  of  the  anterior  third  with 
the  posterior  two-thirds.     These  are  rather  muscular  pareses 


335 


DISEASES  OF  THE  PHARYXX  AXD  LARYNX 


of  the  thyro-arytsenoideus  ^internal  fibres),  than  true  hyper- 
keratoses. 

Symptoms,. — In  subjects  affected  with  nodules,  phonatory 
disturbances  predominate.  The  latter  are  allied  to  the 
lesions  of  catarrhal  laryngitis,  which  almost  always  ac- 
company these  neo-productions. 

The  vocal  alterations  are  easily  observed  in  singers,  when 
they  wish  to  use  the  '  half-tone.' 

On  the  contrary,  during  the  emission  of  low  sounds  there 


Fig.   180. — XoDULES  ox  the  Anterior  Third  of  the  Two  Vocal  Cords. 
Larynx  seen  during  Inspiration. 

is  almost  nothing  perceptible.     The  singer — at  least,  at  the 

outset  and  in  slight  cases — ma}-  overcome  the  obstacle,  which 

momentarily  clogs  his  cords,  and  make  his  voice  tolerably  clear. 

Occasionally,    b\'    listening    closel}-,    diphonia    or    double 


Fig.   181. — Nodules  seen  during  Phonation. 
There  exist  two  crlottic  orifices. 


voice  is  heard.  This  phenomenon  consists  in  the  production 
of  two  sounds  simultaneous  with  the  vocal  emission.  The 
superadded  sound  is  usually  feebler,  and  forms  with  the 
main  sound  a  perfect  third  or  sometimes  an  octave.  The 
explanation   of  this  phenomenon   lies  in   the  fact,  that  the 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     337 

vocal  cord  is  divided  into  two  vibrating  parts  :  one  being 
anterior,  very  short,  and  issuing  from  the  re-entrant  angle 
of  the  cords  to  the  nodulary  point  ;  and  the  other  being 
posterior,  longer,  and  extending  from  the  anterior  contact 
to  the  arytenoid  region. 

Except  complications  there  are  no  other  functional  dis- 
turbances. Nevertheless,  the  subjects  affected  develop  in 
the  interior  of  the  larynx  mucous  secretions,  which  they 
endeavour  to  get  rid  of  by  repeated  '  hemming.' 

Objective  Symptoms. — -The  laryngoscope  is  indispensable 
to  diagnosis.  With  it  may  be  seen  the  integrity  of  the 
vocal  mucosa,  or  a  slight  catarrhal  condition  of  the  cords, 
which  have  lost  their  pearly' appearance,  and  which  present 
on  their  free  edges,  or,  as  is  more  frequently  the  case,  in 
their  anterior  third,  two  small  symmetrical  projections. 
Those  latter  are  acuminate  or  rounded  and  sessile  on  the 
mucous  membrane.  They  resemble  a  small  pin-head  or  a 
grain  of  millet.  When  these  nodulary  thickenings  attain 
a  more  considerable  volume,  they  then  become  true  laryngeal 
polypi.  During  phonatory  efforts  these  nodules  come  in 
contact  with  each  other,  and  thus  hinder  the  vocal  cords 
from  adducting  during  their  whole  length.  It  frequently 
happens,  that  one  of  the  nodules  is  more  bulky  than  its 
fellow  ;  sometimes  the  lesion  only  occupies  a  single  cord. 
It  is  not  rare,  in  somewhat  old  and  grave  forms,  to  see  at 
the  same  time  the  existence  of  paretic  disturbances  bearing 
on  the  ary-arytsenoideus,  or  more  frequently  on  the  internal 
fibres  of  the  thyro-arytaenoideus. 

Similarly,  during  laryngoscopic  examination  the  nodules 
are  frequently  seen  covered  with  a  whitish  viscous  creamy 
secretion,  adherent  to  the  subjacent  mucous  membrane. 
This  secretion  vibrates  with  the  cord  during  phonation. 

During  inspiration  the  nodules  appear  on  the  surface  of 
the  cojrds,  their  edges  almost  blending  with  the  surrounding 
healthy  mucous  membrane.  At  other  times  a  fine  vascular 
network  accompanies  the  hyperplastic  projection. 

Diagnosis  is  generally  easy.  The  profession  of  the  patient 
and  the  aspect  of  the  lesion  are  so  characteristic,  that  it  is 

22 


338  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

difficult  to  confuse  the  nodules  with  other  lesions.  The  cystic 
dilatations  are  usually  single  and  more  projecting  than  the 
nodules  ;  they  are  often  transparent. 

Pathological  Anatomy. — According  to  Sabrazès  and  Frèche, 
the  nodules  are  constituted  histologically  of  hypertrophies 
confined  to  the  epithelium  and  the  mucous  chorion.  Some- 
times the  thickening  of  the  epithelium  is  predominant,  and 
in  those  cases  either  the  hyperplasia  concerns  the  different 
cellular  layers,  or  bears  more  particularly  on  one  of  them, 
and  is  accompanied  either  by  a  hyperkeratosis  or  by 
an  exaggerated  multiplication  of  the  polyhedral  cells,  and 
sometimes  the  chorion  reacts  and  forms  papillary  projec- 
tions. Most  frequently  the  epithelium  and  the  chorion 
participate  in  the  thickening.  This  is  the  more  appreci- 
able, as  the  mucous  coat  of  the  free  edge  of  the  vocal 
cords  is  normally  very  thin,  measuring  from  23  to  26  /x 
(Heymann). 

In  a  case  of  nodule  operated  on  by  the  author,  M.  Sam- 
brazes  observed  a  double  cystic  degeneration,  and,  according 
to  him,  those  dilatations  are  present  en  germe  in  most  nodules 
of  this  description. 

The  encysted  cavities  found  on  examining  histological 
sections  of  nodules  are  due  either  to  the  dilatation  of  vessels 
and  the  lymphatic  spaces  (Chiari),  or  to  mucous  degenera- 
tion of  the  chorion  (Sabrazès),  and  very  rarely  to  glandular 
cysts  (Fraenkel). 

According  to  Garel  and  Bermond,  certain  nodules  may 
be  compared  to  mj'xomatous  or  fibro-myxomatous  buds  of 
the  nasal  fossae. 

Course,  Duration,  Termination. — The  course  of  nodular 
laryngitis  is  slow.  It  undergoes  modifications  and  arrests 
in  development,  according  as  the  persons  affected  continue 
their  ordinary  profession,  and  particularly  the  vocal  abuse 
which  brought  on  the  affection  ;  or  if  they,  on  the  coptrary, 
bring  about  the  disappearance  of  the  morbid  changes,  before 
these  are  completely  established. 

When  the  nodule  appears  as  a  final  symptom  of  muscular 
fatigue    in    singers,    prognosis    is    generally   grave — not    on 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX    339 

account  of  the  projection,  which  it  occasions  on  the  edge  of 
the  cords,  but  on  account  of  the  muscular  disturbances, 
which  accompany  it. 

The  duration  is  very  long,  when  hyperplasia  begins, 
sometimes  extending  to  years.  It  is  difficult  to  say,  if  re- 
currence is  frequent,  as  no  mention  has  been  made  of  it  as 
yet  by  authors,  who  have  studied  the  subject,  though  cases 
of  cure  have  been  generally  noted. 

Prognosis  is  benign,  so  far  as  general  health  is  concerned. 
It  is  only  grave  from  a  professional  point  of  view,  especially 


Fig.   182. — Moure's  Antero-posterior  Laryngeal  Forceps. 


in  singers.  On  the  contrary,  it  is  almost  the  rule  to  see 
infantile  nodules  disappear  with  age. 

Treatment.  —  The  causes,  which  have  given  rise  to  the 
nodule,  should  first  be  suppressed — e.g.,  exaggerated  efforts 
and  displacement  of  the  voice  in  singers,  and  crying  in 
children.  The  nasal  fossae  should  be  free.  This  is  a  fre- 
quent case  of  over-fatigue  of  the  larynx  in  persons  over- 
straining their  voice. 

Finally,  and  above  all,  apply  a  remedy  to  the  over-fatigue, 
or  rather  the  misuse,  of  the  larynx,  of  which  the  nodule  is 
almost  always  the  expression.  Rest  is  the  primary  con- 
sideration.    Hygienic   treatment   and  precautions  are  often 

22 — 2 


340 


DISEASES  OF  THE  PHARYNX  AND  LARYNX 


sufficient  to   make  the  small   commencing  projections  dis- 
appear, and,  if  the  person  so  affected  does  not  fall  back  into 


Fig.   1S3. — Moure's  Lateral  Double-edged  Laryngeal  Forceps. 
A,  To  the  right  ;  B,  to  the  left. 

the  same  errors  as  brought  on  the  first  vocal  disturbance, 
the  affection  may  disappear  for  ever. 

On  the  contrary,  in  graver  cases  when  the  nodule  is  per- 
fectly established,  when  true  local   hyperplasia  exists,  and 


Fig.   li 


-Aubry's  Laryngeal  Forceps  with  Movable  Mount. 


rest  does  not  make  it  completely  disappear,  though  it 
diminishes  it  to  a  certain  extent,  the  sole  treatment  to  employ 
is  removal  of  the  projecting  portion.     Once  the  vocal  mucosa 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     341 

is  anaesthetized,  the  operator  should,  with  forceps  of  small 
calibre,  seize,  and  remove  with  a  single  cut,  the  nodular  pro- 
jection to  the  base  of  its  insertion,  without  injuring  the 
subjacent  vocal  cord.     When  this  operation  is  over,  the  base 


Cauteries  for  the  Larynx, 


should  be  painted  with  a  solution  of  zinc  chloride  (i  in  15). 
The  patient  should  be  left  at  rest  for  several  months  if  he  is 
a  singer,  or  for  several  weeks  if  a  teacher  or  subject  who 
may  only  require  a  speaking  voice. 


Fig.  1S6. — Universal  Handle  for  Cauteries  and  Snares. 

In  much  graver  cases,  accompanied  with  a  true  relaxation 
of  the  whole  mucous  membrane  of  the  cords,  the  operation 
recommended  by  Labus  (decortication  of  the  cords)  should 
be  performed.  A  portion  of  the  glottic  mucosa  should  be 
seized  in  a  forceps,  and  an  attempt  made  to  strip  the  whole 


342  DISEASE'S  OF  THE  PHARYNX  AND  LARYNX 

free  edge  of  the  affected  cord.  This  intervention  will 
necessitate  at  least  a  six  or  ten  months'  rest,  so  that  a 
mucous  membrane  of  new  formation  ma}-  acquire  the  strength 
necessary  for  vocalization. 

This  practice  should  be  reserved  for  the  gravest  cases. 
At  other  times,  if  the  practitioner  is  familiar  with  laryngo- 
scopic  manipulation,  he  may  cauterize  the  nodule  with  the 
galvano-cautery  at  a  dull  red  heat.  Care  must  be  taken  not 
to  make  too  deep  a  cauterization.  It  is  better  to  repeat  the 
burning,  than  to  destroy  too  much  at  first. 

Sprays  of  a  sedative  nature  should  complete  the  above 
surgical  treatment.  In  paretic  forms  electrical  treatment, 
massage,  with  regular  and  methodical  vocal  exercises,  not 
overdone,  are  useful, 

Eversion  of  the  Ventricles. 

This  forms,  as  it  were,  a  corollary  to  benign  tumours  of 
the  larynx,  and  is  well  known.  It  does  not  consist,  as  the 
title  of  this  chapter  appears  to  indicate,  in  luxation  inwards 
of  the  mucous  membrane  of  the  ventricle  of  Morgagni,  but 
in  a  more  of  less  considerable  projection  of  the  mucous 
membrane,  which  lines  these  cavities.  Cases  of  this  kind, 
formerly  considered  rare,  are  being  commonly  observed,  since 
Fraenkel's  monograph  on  the  subject. 

The  ventricular  tissue,  being  closely  adherent,  making,  as 
it  were,  one  with  the  perichondrium  of  the  thyroid  cartilage 
on  the  one  side  and  with  the  base  of  the  epiglottis  and  the 
arj'tenoids  on  the  other,  cannot  possibly  be  luxated  and 
everted  inwards.  Accordingly,  even  when  the  projecting 
portion  is  ver}^  considerable,  we  have  not  to  deal  with  a 
true  ventricular  eversion,  but  with  an  inflammatory  ridge 
connected  with  the  deep  tissue  and  blending  with  it. 

Etiology — Forms. — The  lesion  may  supervene  in  acute 
form  after  a  simple  catarrh.  Most  frequently  this  abnormal 
projection  is  consequent  on  chronic  inflammations  of  the 
laryngeal  mucosa,  and  occurs  by  preference  in  people  ex- 
posed to  the  usual  causes  of  chronic  larjmgitis  (irritating 
dust,  vapours,  singers  and  speakers). 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     343 

It  is  common  to  see  the  prolapsus  suddenly  supervene 
(Lussan). 

At  the  first  stage  a  mere  redness  is  observed  on  the  inferior 
edge  of  the  ventricular  band,  the  rest  of  the  vocal  mucosa 
being  perfectly  healthy  (Stoerck). 

Functional  disturbances,  merely  vocal,  can  be  noticed  only 
in  singers,  more  particularly  m  soprano  and  light  tenor  voices. 

At  the  second  stage  the  orifice  of  the  ventricle  disappears, 
and  is  replaced  by  a  small  projection.  Instances  of  this 
inflammatory  prolapsus  are  common  in  infectious  laryngitis 
(tuberculosis,  syphilis). 

At  the  third  stage  the  ventricular  tumour,  owing  to  the 
increasing  proliferation  of  the  connective  tissue,  assumes  the 
appearance  of  a  polypus  with  a  sessile  base  occupying  the 
ventricular  space. 

To  this  stage  is  applied  the  name  of  eversion  of  the 
ventricles. 

Syviptoms.  —  Functional  symptoms  are  almost  nil  at  the 
beginning,  except  in  singers,  whose  voices  rapidly  become 
exhausted  and  sometimes  husky.  At  this  period  ttie  symp- 
toms pass  unperceived,  as  they  may  as  well  belong  to  any 
other  simple  laryngitis.  It  is  only  at  the  confirmed  stage, 
when  the  mucosa  is  projecting  and  covering  partly  or  com- 
pletely one  or  both  vocal  cords,  that  vocal  disturbances  are 
pronounced.  The  voice  is  veiled,  even  aphonic,  and  stifled, 
if  the  tumours  are  bulky. 

Respiration  is  not  changed  in  its  rhythm,  unless  the  two 
prominent  ventricular  mucous  membranes  make  the  glottic 
orifice  noticeably  narrower.  Even  in  that  case,  if  the 
arytenoids  are  mobile,  there  passes  into  the  intercartilaginous 
glottis  sufficient  air  to  prevent  dyspnœa  from  being  intense. 
Exception  is,  of  course,  to  be  made  in  cases,  where  eversion 
is  symptomatic  of  a  neoplasm,  or  of  a  grave  lesion  of  the 
vocal  mucosa. 

Cough  is  absent,  except  in  acute  forms,  and  it  is  then, 
as  a  rule,  consequent  on  lesions  accompanying  ventricular 
tumefaction. 

According  as  the  projection  is  uni-  or  bi-lateral,  laryngo- 


344  DISEASES  OF  THE  PHARYNX  AXD  LARYXX 

scopic  examination  shows  on  one  or  two  sides  of  the  larynx 
either  a  simple  swelling  masking  the  ventricular  orifice,  or, 
in  more  pronounced  cases,  one  or  two  tumours,  smooth  on 
their  surface,  occupying  the  whole  external  part  of  the 
larynx,  and  more  or  less  covering  the  underlying  vocal  cord, 
and  connected  with  the  ventricular  band  by  a  small  excava- 
tion, often  difficult  to  perceive,  so  that  the  ventricular  band 
seems  to  be  one  with  the  mucosa. 

The  swollen  parts  are  slightly  redder  than  the  rest  of  the 
vocal  mucosa.  Under  the  probe  they  are  resilient,  softish, 
sometimes  even  partly  reducible.  In  some  cases  the  bulk 
of  the  tumour  diminishes  after  painting  with  a  solution  of 
adrenalin  and  cocaine.  It  may  even  be  almost  entirely 
reduced,  but  projects  again  soon  afterwards  into  the  laryn- 
geal orifice.  When  bulky,  it  is  seen  to  move  to  and  fro 
during  phonation  and  inspiration.  Sometimes  the  ventricular 
mucosa  is  seen  during  movements  of  deep  inspiration. 

Eversion  may  occupy  onlv  the  anterior  or  posterior  part 
of  the  larynx,  forming  there  a  small  smooth  tumour,  blending 
with  the  ventricular  band.  Those  partial  tumefactions  are 
not  uncommon. 

Diagnosis. — Diagnosis  is  not  always  easy,  as  a  ventricular 
tumour  (angiomyxomatous  polypus,  cysts,  etc.)  may  simulate 
a  ventricular  eversion. 

A  careful  examination  usually  ensures  an  exact  diagnosis 
by  determining  whether  the  tumour  is  merely  inflammatory 
and  catarrhal,  or,  on  the  contrary,  secondary  to  syphilis, 
tuberculosis,  or  to  even  a  malignant  tumour  of  the  larynx. 

In  rarer  cases  histological  examination  alone  is  able  to 
settle  the  diagnosis. 

Treatment. — Some  authors  formerly  advised  reduction  of 
the  ventricular  mucosa  by  means  of  the  probe  and  by  paint- 
ing the  inflamed  region  with  astringent  solutions,  but  this 
treatment  fails  in  most  cases. 

Chemical  or  galvanic  cauterization  should  be  applied  to 
incipient  hypertrophy  ;  but  the  author  thinks,  that  volu- 
minous tumours  should  be  removed  with  the  cutting  forceps 
in    the    same    way    as    polypi,    at    one    or    several    sittings, 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     345 

according  to  their  size.  The  neoplasm  may  sometimes  be 
removed  by  thyrotomy,  the  incised  thyroid  cartilage  being 
immediately  reunited. 

Galvano-cautery  should  be  employed  in  some  cases  after 
removal,  either  to  arrest  haemorrhage  or  to  shrivel  up  the 
parts  of  the  mucosa  injured  by  the  forceps. 

Laryngocele. 

Though  known  for  a  long  time,  this  is  not  a  very  common 
tumour. 

Etiology. — The  cause  of  laryngocele  is  the  same  as  that  of 
tracheocele.  It  may  in  a  general  way  be  admitted,  that  those 
gaseous  tumours  are  produced  by  rupture  of  the  air  tract  and 
by  effusion  of  air  into  the  neighbouring  regions,  or  through 
hernia  of  the  soft  parts,  between  the  cartilages  of  the  larynx. 
These  two  lesions  follow  a  traumatism  or  a  violent  effort  {e.g.,  a. 
fit  of  coughing)  of  any  kind.  The  author  once  saw  a  hernia  of 
the  laryngeal  mucosa,  at  the  level  of  the  middle  part  of  the 
ventricle  of  Morgagni,  in  the  course  of  a  spasmodic  bronchitis. 
Sometimes  the  formation  of  those  tumours  is  facilitated  by 
particular  anatomical  dispositions  (ventricular  laryngocele), 
consisting  in  a  prolongation  of  the  ventricles  of  the  larynx 
to  the  level  of  the  hyoid  or  even  of  the  sublingual  mucosa. 

Symptoms  are  aJmost  similar  to  those  of  all  the  gaseous 
tumours  in  the  region  of  the  neck.  Generally,  their  site, 
smooth,  rounded  shape,  their  reduction  by  pressure  or  mas- 
sage, and  their  resonance,  when  the  projection  is  bulky  enough 
to  be  percussed,  are  characteristic  signs  of  laryngocele. 

It  is  not  always  easy  to  reduce  the  tumour,  as  the  orifice 
of  its  communication  with  the  larynx  may  be  very  narrow. 
In  those  cases  the  nature  of  the  distension  of  the  sac  and  its 
gaseous  consistency  are  recognized  with  difficulty. 

Prognosis  is  generally  benign,  as  the  lesion  has,  if  treated, 
no  tendency  to  extend,  provided  the  patient  does  not  expose 
himself  to  over-violent  efforts. 

Treatment  depends  on  the  volume  of  the  tumour,  site  of  the 
lesion,  and  the  disturbances  produced.  It  may  be  left  alone 
or  the  tumour  simply  restrained  by  a  plug  of  cotton-wool, 


346  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

etc.  At  other  times  removal  of  the  distended  sac  should  be 
carried  out,  an  incision  being  made  on  the  tumour  and  the 
bag  resected.  The  lips  of  the  mucous  membrane  are  joined 
by  a  continuous  suture,  the  tissue  of  the  larynx  with  catgut, 
and  the  skin  with  horsehair.  This  operation  is  not  always 
easily  effected,  as  it  is  difficult  to  get  at  the  sac,  which 
cannot  be  inflated  during  the  operation  ;  yet,  if  the  patient's 
life  is  endangered,  such  is  the  sole  resort. 

Malignant  Tumours  (Cancer  of  the  Larynx). 

Etiology. — This  affection  may  be  said  to  occur  exclusively 
in  adults,  especially  between  forty  and  sixty,  although  some 
cases  have  been  observed  in  children.  Men  are  more  exposed 
to  it  than  women,  owing,  perhaps,  to  abuse  of  tobacco,  alcohol, 
or  vocal  effort,  or  probably  to  the  individual  structure  of  the 
larynx.  The  author  attributes  it  chiefly  to  heredity  or  to 
certain  obscure  predispositions  of  the  individual. 

Cancer  of  the  larynx  is  rather  common  in  subjects,  who 
have  a  vigorous  appearance  (arthritic  people). 

The  author  has  seen  an  example  of  a  secondary  malignant 
tumour  in  the  larynx,  consequent  on  cancer  of  the  rectum 
(epithelioma). 

Finally,  certain  benign  tumours  may  become  malignant. 

Malignant  tumours  may  be  classified  into  two  groups  : 
(i)  extralaryngeal,  and  (2)  intralaryngeal. 

(a)  Functional  Symptoms. — Those  are  vague  at  the  outset, 
may  pass  unperceived,  and  vary  somewhat,  according  to  the 
site  of  the  neoplasm.  In  intralaryngeal  tumours  on  the 
vocal  cords  alteration  of  the  voice  constitutes  the  first 
symptom,  and  may  precede  for  three,  four,  or  five  years 
the  confirmation  of  the  nature  of  the  malady.  As  the 
tumour  increases  in  bulk  and  develops,  the  voice  becomes 
raucous,  rough,  unequal,  and,  as  it  were,  'wooden'  (Fauvel). 
At  a  more  advanced  stage  it  is  veiled,  even  aphonic,  and  the 
patient  appears  to  speak  without  using  his  vocal  cords. 

When  the  tumour  is  extralaryngeal,  the  disturbances  of 
phonation  are  absent  for  a  fairly  long  time,  while  those  of 
deglutition,  on  the  contrary,  appear  rather  early.     At  first 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     347 

the  patient  complains  of  a  slight  pain  at  the  time  of  the 
passage  of  the  bolus.  Modifications  of  the  voice  only 
appear,  when  the  entrance  of  the  lar3'nx  is  more  or  less 
obstructed  by  the  tumour,  or,  when  a  side  of  the  larynx  is 
immobilized  through  infiltration.  Cough  is  rare  at  the 
beginning.  In  extralaryngeal  tumours,  there  is  less  a  true 
cough  than  a  desire  to  clear  the  throat. 

Expectoration,  absent  at  first,  later  on  becomes  mucoid, 
muco-purulent,  purulent,  and  even  sanious.  The  presence 
of  blood  in  the  secretions  is  an  important  element  in  diagnosis. 

At  a  more  advanced  stage  expectoration  chiefly  consists  of 
saliva,  which  the  patient  can  no  longer  swallow. 

Respiratory  disturbances,  hardly  appreciable  at  first,  vary 
later  on,  according  to  the  site  and  the  volume  of  the  tumour. 
When  the  latter  is  inside  the  lar3mx  (ventricular  bands, 
cords),  respiratory  difficulty  occurs  very  early,  and  may 
become  intense,  the  cords  being  immobilized,  and  the 
neoplasm  partly  obstructing  the  glottic  orifice. 

If  the  swelling  occupies  both  sides  of  the  larynx,  the  two 
arytenoids  are  immobilized,  the  air  passes  with  great  diffi- 
culty, and  there  results  from  that  condition  a  harsh  respira- 
tion— 'wooden'  (ligneuse),  Fauvel. 

In  this  form  of  endolaryngeai  cancer  and  at  this  stage 
respiration  is  noisy,  fits  of  suffocation  occur  on  the  least 
irritation,  and  the  patient  may  die  suddenly,  if  the  trachea 
is  not  opened. 

When  the  tumour  is  extralaryngeal  (epiglottis,  aryepi- 
glottic  folds,  oesophageal  orifice),  respiratory  disturbances, 
apart  from  exceptional  cases,  appear  at  the  very  last  stage 
of  the  lesion.  When  the  growth  fills  the  pyriform  cavity 
and  from  the  infiltration  immobilizes  one  or  both  sides  of 
the  lar3'nx.  Exceptionally  also  do  we  see  early  asphyxia. 
It  is  only  when  the  neoplasm  has  then  acquired  an  excessive 
volume  resembling  a  mushroom  with  a  broad  peduncle,  and 
if  aspirated  during  inspiration,  will  cause  asphyxia.  At  this 
stage  deglutition  is  so  much  compromised  and  the  patient 
so  profoundly  cachectic,  that  there  is  sometimes  hesitation  in 
performing  tracheotomy.     It  must  not  be  forgotten,  however, 


348  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

that  those  extralaryngeal  cancers  invade  the  oesophagus,  and 
the  larynx  is  immobihzed  in  a  neoplastic  mass,  involving 
also  the  trachea  and  the  nerves  of  the  region  (pneumo-gastric, 
superior  laryngeal,  récurrents),  so  that  the  opening  of  the 
air  tract  does  not  afford  any  respiratory  relief  to  the  patient. 

Paiji,  absent  at  the  outset,  becomes  pronounced,  when  the 
tumour  reaches  the  stage  of  confirmation.  It  appears  earlier 
in  the  case  of  extralaryngeal  neoplasms,  and  persists  till  the 
end  of  the  lesion.  The  pain  is  characterized  by  being  spon- 
taneous, shooting,  and  by  radiating  not  only  towards  the  corre- 
sponding ear,  but  also  to  the  nape  of  the  neck  and  the  vertex. 
It  may  be  roused  and  intensified  by  movements  of  deglutition, 
or  by  any  other  disturbance  of  the  part.  This  spontaneous 
neuralgic  pain  is  very  exhausting,  and  it  is  particularly  acute 
in  the  ear,  when  the  neoplasm  occupies  one  of  the  ary-  or 
glosso-epiglottic  folds. 

Salivation  is  specially  abundant  in  the  case  of  neoplasms 
situate  outside  the  larynx,  owing  to  the  difficulty  of  degluti- 
tion and  to  the  exaggerated  secretion  of  the  salivary  glands. 
The  saliva  is  generally  thick,  viscous,  and  sanious.  The 
expectoration  is  muco  -  purulent,  or  even  purulent,  and 
sometimes  contains  detritus  of  sphacelated  tumour,  and  is 
frequently  mixed  with  blood,  being  at  times  completely 
haemorrhagic.  The  latter  fact  constitutes  an  important 
element  of  diagnosis  (Fauvel).  Haemorrhages  chiefly  occur 
in  extralaryngeal  tumours,  and  may  be  sufficiently  abundant 
to  endanger  life. 

One  of  the  foregoing  symptoms  often  predominates, 
according  to  the  seat  of  the  tumour. 

(6)  Objective  Symptoms. — If  the  symptoms  experienced  by 
the  patient  suggest  the  diagnosis,  laryngoscopic  examination 
alone  enables  us  to  verify  the  lesion,  to  ascertain  its  site,  its 
form,  and  its  morphological  character. 

When  the  cancer  starts  in  a  ventricular  band,  a  mere 
swelling  of  a  deep  red  hue  is  at  first  perceived,  accompanied 
by  slight  œdema  of  the  neighbouring  parts.  The  swollen 
region  is  not  smooth  and  even,  but  is  somewhat  mammillated. 
If  the  lesion  is  situate  posteriorly,  the  corresponding  ary- 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     349 

tenoid  soon  becomes  slightly  infiltrated  and  less  mobile  than 
its  fellow.  Should  the  neoplasm  occupy  one  of  the  vocal 
cords,  it  then  appears,  and  especially  in  old  people,  as  a 
greyish  tumour  of  a  villous,  papillary  appearance,  attached 
by  a  broad  base  to  the  vocal  cord,  which  is  swollen,  uneven, 
and  rosy  in  places.  At  this  stage  there  is  no  peripheral 
oedema,  and  the  cancer  might  be  mistaken  for  a  small  diffuse 
papilloma,  or  a  varicose  condition  of  the  cord.  The  neigh- 
bouring parts  are  intact.  The  lesion  may  remain  stationary — 
at  least,  apparently  so — for  months,  and  even  for  years,  when 
it  becomes  surrounded  by  an  œdematous  tumefaction,  which 
gradually  invades  the  ventricular  bands  and  the  arytenoid 
region,  and  soon  afterwards  the  cord  becomes  immobilized  in 
the  middle  line.    At  the  stage,  where  laryngeal  cancer  presents 


Fig.  1S7. — Early  Epithelial  Cancer  of  the  Right  Vocal  Cord. 

its  usual  classical  appearance,  this  morbid  degeneration  varies 
according  to  its  anatomo-pathological  constitution. 

Epithelioma. — This  variety  of  cancer  is  by  far  the  most 
frequent,  and  has  the  appearance  of  a  reddish,  mammillated, 
anfractuous  tumour,  with  granular,  ulcerated  edges,  covered 
with  cauliflower-like  masses  of  a  sanious  appearance.  The 
tissue  appears,  as  if  sprinkled  over  with  very  fine  sand.  At 
other  times  the  lesion  is  accompanied  by  mere  cancerous 
infiltration,  with  rugose  appearance,  and  is  characteristically 
surrounded  by  oedema.  Later  on  peripheral  infiltration  is 
considerable  ;  the  organ  is  deformed,  becomes  ulcerated  and 
covered  with  greyish,  blackish,  sanious  detritus.  It  bleeds 
very  readily. 

Encephaloid. — The  swelling  is  more  uniform,  is  slightly 
mammillated,  and  covered  with    buds,  which    are   sanious. 


3SO  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

greyish,  and  sphacelated  here  and  there.  Ulceration  occurs 
early,  and  mushroom -like  granulations  with  large  peduncles 
develop  at  its  surface.  The  neoplasm  is  generally  extra- 
laryngeal. 

Sarcoma. — Sarcoma  seems  to  be  less  frequent  than 
epithelioma.  It  is  sometimes  inserted  by  a  broad  base  on 
the  epiglottis,  or  on  its  folds,  or  on  the  mucosa  of  the  cords. 
Occasionally  it  is  almost  pedunculated,  and  appears  as  a 
large  verrucose  tumour  of  red  or  yellowish  hue,  made  up  of 
small  isolated,  readily-bleeding  projections.  Those  tumours 
may  attain  to  an  enormous  bulk  (hen's  egg),  and  be  projected 
into  the  mouth  during  the  act  of  expectoration.  The  author 
has  seen  those  neoplasms  become  sphacelated  through  local 


Fig.  i88. — Sarcoma  of  the  Laryngeal  Surface  of  the  Epiglottis. 
(From  Nature.) 

infection  (diphtheria,  influenza),  and  be  partly  expectorated 
in  an  effort  of  vomiting.  Microscopic  examination  alone 
permits  recognition  of  the  varieties  of  sarcoma. 

Melanitic  Tumours. — Those  are  exceptionally  rare 
(two  cases  are  noted  by  Sir  Morell  Mackenzie),  and  are 
recognizable  by  a  sanious,  blackish,  generally  characteristic 
appearance. 

Siie. — The  parts  of  the  larynx  most  frequently  affected  by 
malignant  tumours  are  the  ventricular  bands  and  the  vocal 
cords  (endolaryngeal  cancers)  and  the  arytenoid  region 
(extralaryngeal).  External  modifications  of  the  larynx  and 
the  neck  only  appear,  when  diagnosis  is  already  clear  to  a 
skilled  observer.  In  the  case  of  an  endolaryngeal  cancer  it 
is,  when  the  tumour  is  ulcerated,  and  the  above  symptoms 
are  at  an  advanced  stage,  that  thé  thyroid  becomes 
hypertrophied  and  carapace-like  in  form  (Isambert).     The 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     351 

thickened  cartilage  then  forms  in  front  and  on  the  sides 
of  the  larynx,  as  it  were,  a  shield,  characteristic  of  the 
neoplastic  infiltration,  which  generally  invades  it  from 
within  outwards.  The  neck  becomes  swollen,  as  glandular 
involvement  also  appears,  forming  with  the  tumefied  larynx 
a  hard  '  wooden  '  and  immobile  mass. 

When  the  tumour  is  extralaryngeal,  the  characteristic 
adenopathy  (the  deep  glands,  hardened  en  masse,  painful  and 
adherent  to  the  deeper  structures)  appears  early,  and  occupies 
the  side,  on  which  the  degeneration  has  originated,  or  even 
both  sides  of  the  submaxillary  or  the  carotid  region. 


Fig.  189. — Epu!ILLi^..ia  of  the  Right  Ventricular  Band. 

According  to  the  site  of  the  cancer,  adenopathy  often 
occurs  at  the  angle  of  the  jaw,  slightly  below  the  parotid 
gland.  At  this  stage  the  larynx  is  almost  entirely  immobilized  ; 
the  whole  region  of  the  neck  is  hard,  'wooden,'  painful  to  the 
touch,  and  shows  protuberances.  Softening  of  the  glandular 
mass  may  occur,  with  abscess  formation,  from  which  an 
ichorous,  sanious  liquid  escapes.  The  surface  of  the  broken- 
down  gland  is  covered  with  greyish  buds,  forming  at  its 
surface  a  mushroom-shaped  neoplasm. 

An  important  symptom,  which  is  seldom  absent  in  cancer 
of  the  posterior  region,  is  the  loss  of  laryngeal  crepitation. 
When  the  larynx  in  the  normal  state  is  moved  laterally,  a 
characteristic  crepitus  is  perceived.  This  disappears  on  one 
or  both  sides  as  soon  as  the  fibro-cartilage  (cricoid)  becomes 
infiltrated. 


352  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

Pathological  Anatomy. — Malignant  tumours  of  the  larynx 
do  not  differ  from  those  of  other  organs.  The  only  fact  to 
point  out  here  is,  that  diagnosis  of  cancer  is  not  always 
easily  settled  at  the  outset,  and  that  microscopic  examina- 
tion of  several  portions  removed  by  the  forceps  should  be 
made. 

Course — DiLvation.  —  The  course  of  the  affection  varies 
according  to  the  nature  of  the  neoplasm  and  the  age  of  the 
patient.  Extralaryngeal  cancers  being  more  liable  to  irrita- 
tion (passage  of  the  bolus,  movements  of  deglutition),  have 
a  more  rapid  course  than  those  situate  inside  the  larynx. 
Thus  malignant  tumours  originating  on  the  vocal  cords  of 
elderly  subjects  develop  slowly,  and  may  remain  as  if 
stationary  for  years,  causing  no  other  functional  disturbance 
than  huskiness. 

When,  on  the  other  hand,  the  neoplasm,  under  the  influence 
of  local  irritation  or  any  other  cause,  has  begun  to  extend, 
and  a  fortiori,  when  ulceration  and  budding  have  appeared, 
the  disease  then  progresses  rather  rapidly.  After  respiratory 
disturbances  have  rendered  tracheotomy  necessary,  death 
usually  ensues  within  one  or  two  years.  Thyroid  peri- 
chondritis and  glandular  involvement  also  occur,  indicating 
the  diffusion  of  the  neoplasm,  and  ushering  in  the  cachectic 
stage. 

Termination — Prognosis. — Cancer  of  the  larynx  is  a  very 
grave  affection,  and  incurable  if  left  alone.  The  patient  dies 
either  from  asphyxia  or  from  inanition  or  cachexia.  Asphyxia 
results  not  only  from  the  obstruction  of  the  air  tract  (bulk  of 
the  neoplasm,  infiltration  of  the  neighbouring  parts,  im- 
mobilization of  the  arytenoids),  but  also  from  the  compression 
of  the  récurrents  and  even  of  the  pneumogastrics.  The 
neoplasm  involves  the  whole  region  of  the  neck  (oesophagus 
included),  causing  respiratory  and  circulatory  embarrassment. 
Death  usually  occurs  from  bulbar  syncope,  and  that  in  spite 
of  the  tracheal  canula,  and  of  the  free  penetration  of  air  into 
the  still  unaffected  portion  of  the  trachea. 

The  infiltration  of  the  peritracheal  glands  and  their 
degeneration   may  also  cause  respiratory  stenosis  by  com- 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     353 

pression  of  the  trachea  and  of  the  first  divisions  of  the 
bronchi. 

At  this  stage  the  larynx  is  entirely  immobilized  in  the 
midst  of  diseased  tissues,  a  condition  which  renders  alimen- 
tation difficult  and  painful. 

Certain  sarcomata  and  pavemented  epitheliomata  situated 
on  a  cord,  if  treated  before  the  infiltration  stage,  seem  to  be 
less  malignant. 

Complications. — In  the  case  of  an  endolaryngeal  cancer, 
after  tracheotomy  has  been  performed,  the  neoplasm  may 
extend  to  the  trachea  below  the  opening,  and  cause  asphyxia. 

Haemorrhage  is  also  a  dangerous  complication,  as  it  is 
difficult  to  combat. 

Diagnosis. — Diagnosis  is  easy  in  some  cases,  especially  at 
the  stage  of  confirmation,  but  at  the  beginning  it  presents 


Fig.  190. — Canula  for  Tracheotomy,  with  Pean's  Pilot. 

certain  difficulties.  It  does  not  seem  necessary  to  describe  the 
differential  diagnosis  between  polypi  of  the  larynx  and  cancer. 
Certain  horny  papillomata  with  a  broad  base,  observed  in 
old  people,  might  perhaps  give  rise  to  suspicion,  but  those 
tumours  are  rare  ;  and,  besides,  histological  examination  would 
remove  all  doubt.  The  existence  of  peripheral  infiltration, 
and  especially  the  immobility  of  a  vocal  cord,  would  point  to 
a  malignant  degeneration. 

Laryngeal  tuberculosis  is  seldom  limited  to  one  cord  ;  as  a 
rule,  the  lesions  are  more  superficial;  the  buds,  if  present, 
are  paler,  more  diffuse,  and  are  in  the  pseudo-polypoidal 
form.  The  interarytenoid  region  exhibits  the  usual  char- 
acters of  bacillary  infection. 

Laryngeal  lupus,  having  a  marked  predilection  for  the  epi- 
glottis, exhibits  pale,  rosy  granulations,  destroying  the  under- 

23 


354  DISEASES  OF  THE  PHARYNX  AXD  LARYNX 

lying  tissues,  and  cannot  be  confused  with  malignant  tumours, 
except  for  a  very  short  time  at  the  very  beginning. 

In  some  very  rare  cases,  however,  where  the  lupoid  lesion 
is  so  well  limited  to  the  operculum,  especially  if  the  patient 
is  old  or  otherwise  healthy,  histological  examination  alone 
can  dispel  all  doubts.  Lupus]  is  painless,  whereas  cancer  is 
usually  painful,  spontaneously  or  otherwise. 

Syphilis  during  the  secondary  stage  presents  no  analogy 
with  cancer,  but  in  the  tertiary  stage  it  is  difficult  some- 
times to  be  certain  of  the  diagnosis.  It  should  be  kept  in 
mind,  that  gummata  generally  have  their  seat  on  the 
epiglottis,  one  of  the  ventricular  bands,  the  ventricular 
mucosa,  or  the  subglottic  region. 

The  evolution  of  the  affection  should  be  taken  into  account, 
besides  its  history.  Gumma  produces  within  two  or  three 
months  first  vocal,  then  respiratory  disturbances,  if  specific 
treatment  has  not  been  applied.  The  course  of  cancer,  on  the 
contrary,  is  much  slower;  moreover,  the  localization  is  different. 

The  gumma  appears  as  a  diffuse  infiltration,  red,  it  is  true, 
but  without  protuberances  or  hypersecretion.  Neither  spon- 
taneous pain  nor  blood-streaked  expectoration  is  present. 
At  the  stage  of  ulceration  the  syphilitic  loss  of  substance  is 
crateriform,  serpiginous,  and  deeply  penetrates  into  the 
tissues  ;  its  surface  is  greyish  and  dirty,  suppurative,  and  is 
accompanied  by  reddish  budding,  peripheral  infiltration, 
sometimes  with  perichondritis.  In  spite  of  extensive  lesions, 
the  vocal  cords  often  remain  mobile.  Finally,  the  ulcer 
spreads  upwards,  gradually  reaching  the  base  of  the  tongue, 
the  tonsils  and  the  lateral  walls  of  the  pharynx  deforming 
and  destroying  the  affected  parts. 

Tertiary  manifestations  are  often  found  on  the  soft  palate, 
the  palatine  vault,  or  in  the  naso-pharynx,  and  diagnosis  is 
thereby  facilitated. 

Finally,  all  doubt  is  dispelled  by  specific  treatment,  which 
is  rapidly  efficacious  in  syphilis  (a  week  or  even  two  days), 
whereas  in  cancer  its  effects  are  usually  absent,  or  at  least  very 
slight  and  transitory. 

Hybrid   forms  sometimes  occur.     In   those  cases  diffuse. 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     3^^ 

suppurating-,  crateriform  ulceration,  with  a  dirty  and  greyish 
base,  should  be  attributed  to  syphilis,  whereas  cancer  accounts 
for  the  sanious,  fetid  buddings,  accompanied  by  reddish, 
hardened  infiltrations. 

The  existence  of  spontaneous  and  neuralgic  pains,  accom- 
panied with  bloody  expectoration,  suggests  malignant  tumour. 
In  this  case  specific  treatment  cures  the  syphilitic  infection, 
but  the  neoplasm  follows  its  slow  and  progressive  evolution. 

In  those  hybrid  forms,  which  usually  develop  outside  the 
larynx,  it  is  not  unusual  to  observe  an  extensive  adenopathy, 


Fig.  191. — Ruault's  Punch  Forceps. 


irregular  on  its  surface,  adherent,  'wooden,'  and  painful  to 
the  touch. 

Treatment. — Some  authors  still  advise  abstention  from 
operation,  or  tracheotomy  as  a  palliative  remedy,  when 
asphyxia  is  threatening.  Others,  on  the  contrary,  favour  more 
radical  operations,  such  as  removal  of  the  tumour  by  the 
external  method,  partial  or  even  total  extirpation  of  the  larynx. 

Painting  with  tincture  of  thuja  or  of  celandine,  or  with 
their  extracts,  or  even  with  solution  of  adrenalin  (i  :  1,000), 
may  check  the  budding,  but  they  do  not  in  any  way  arrest 
the  progress  of  the  tumour. 

The  efficiency  of  the  X  rays  and  of  radium  is  not  yet 
adequately  worked  out. 

23—2 


356 


DISEASES  OF  THE  PHARYNX  AND  LARYNX 


(a)  Natural  Tract. — A 
few  authors  are  still 
in  favour  of  extraction 
through  the  mouth. 
Although  this  method 
has  given  good  results 
in  exceptional  cases  (very 
limited  neoplasm.s),  it 
should  not  be  generally 
employed.  The  cancer 
not  only  recurs,  but  also 
assumes  an  acute  course, 
and  it  is  unfortunately,  as 
yet,  impossible  to  deter- 
mine which  tumours  are 
susceptible  of  cure  by 
this  method.  For  that 
reason  the  author  thinks, 
that  the  endolaryngeal 
method  should  be  em- 
ployed only  to  confirm 
diagnosis. 

(6)  Tracheotomy. — The 
diagnosis  of  laryngeal 
cancer  is  generally  made 
too  late.  The  patient 
seeks  for  advice  when 
he  experiences  difficulty 
in  breathing  —  i.e.,  at 
the  stage  of  infiltration. 
Hence  some  authors 
hesitate  to  perform  a 
radical  operation,  and 
advise  tracheotomy,  to 
prevent  immediate  death. 
In  cases  of  intralaryn- 
geal  neoplasms  the  opening  of  the  trachea,  practised  at  this 
stage,  protracts  the    life    of  the   patient   for  from   eighteen 


Fig.  192. — Laryngeal  Curettes  mounted 
ON  Separate  Handles. 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     357 

months  to  two  years.  On  the  contrary,  if  the  tumour  is 
extralaryngeal,  tracheotomy  does  not  prolong  life  much  ;  the 
patient  dies,  if  not  from  asphyxia,  from  inanition  and  cachexia. 

In  certain  advanced  cases  the  extension  of  the  lesion  renders 
removal  of  the  affected  parts  almost  impossible,  and  some 
operators  prefer  to  practise  tracheotomy,  when  this  becomes 
imperative.  The  latter  operation  should  then  be  made  as 
low  down  as  possible,  in  order  to  avoid  the  tumour,  and  to 
prevent  the  buds  from  reaching,  later  on,  the  tracheal  tube. 

It  is  well  to  recall  that  tracheotomy  in  cancerous  people 
is  very  different  to  that  carried  out  in  the  case  of  children. 
In  adults,  the  bloodvessels  are  large,  the  veins  much  dilated, 
the  tracheal  tube  deeply  situated;  the  neck  may  be  short, 


Fig.  193. — Tubular  Canule,  with  Pean's  Handle. 

thickened,  and  sometimes  infiltrated — all  conditions  which 
make  the  operator  careful  not  to  take  any  regrettable  risk. 
The  operator  should  therefore  proceed  slowly  layer  by  layer, 
ligaturing  the  vessels  with  catgut  before  opening  the  air  dnct. 

The  trachea,  once  laid  bare  and  under  good  illumina- 
tion, should  be  incised,  as  usual,  with  a  straight,  rather  short, 
and  well-sharpened  bistoury.  Care  must  be  taken,  that  the 
inferior  part  of  the  incision  should  be  under  observation  all 
the  time,  and  that  no  bloodvessel  is  divided,  and  left  bleeding, 
as  haemorrhage  is  then  always  serious. 

The  trachea  should  be  opened  under  full  inspection  ;  the 
lips  of  the  incision  (pretracheal  tissues)  should  be  held  apart 
b}'  two  special  retractors,  and  the  forcipressure  forceps  may 


358 


DISEASES  OF  THE  PHARYNX  AND  LARYNX 


be  used  to  clamp  the  two  ends  of  the  divided  thyroid  body. 
That  being  accomphshed,  the  canula  is  introduced  by  the 
assistance  of  Pean's  or  Krishaber's  instrument,  which  has 
the  enormous  advantage  of  dispensing  with  the  dilator,  an 
instrument  responsible  for  many  mistakes  in  the  hands  of 
young  and  anxious  surgeons  during  the  introduction  of  the 
canula. 

It  is  important,  during  the  introduction  of  the  canula,  that 
the  patient's  head  should  be  kept  strongly  bent  back,  as  it  was 
during  the  operation,  and  frequently  it  is  of  advantage  to 


Fig.  194. — Tracheotomy  Canula,  with  Flexible  Tubes. 

maintain  the  trachea  steady  and  raised  up  with  the  assistance 
of  a  tenaculum  fixed  under  the  cricoid  ring.  In  this  way  a 
clean  and  well-defined  incision  is  obtained. 

The  canula  being  once  in  place,  the  wound  should  be 
dressed  aseptically,  and  a  layer  of  warm,  dr}^  gauze  applied 
in  front  of  the  neck  to  filter  the  air  which  enters  the 
lungs.  If  desirable,  a  few  sutures  may  be  used  to  bring  the 
edges  together,  but  it  should  be  remembered  that  it  is  desir- 
able to  leave  the  wound  open  above  the  canula  and  so  avoid 
subsequent  emphysema. 

The  operation  is  performed  under  chloroform  or  after  a 
simple    subcutaneous    injection    of    cocaine.     The    former 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     359 

method  is  to  be  preferred  when  the  respiration  is  still  good 
and  there  is  no  danger  of  asphyxia.  The  latter  is  indicated 
when  the  tumour  is  large  and  respiratory  disturbance  con- 
siderable. In  some  cases,  where  the  patient  cannot  remain 
lying  on  account  of  respiratory  stenosis,  he  should  be  operated 
on  sitting  in  an  armchair,  his  head  being  bent  backwards. 
This  position  is  favourable  for  operations. 


3c\^ 


Fig.   195. — Line  of  Cutaneous  Incision  in  Median  Thyrotomy. 
I,  Hyoid  bone  ;  2,  sternal  notch  ;  3,  sternum  ;  4,  mental  symphysis. 

When  diagnosis  is  made  early,  the  radical  operation  is 
called  for,  which,  according  to  the  case,  consists  in  opening 
or  in  partial  or  total  extirpation  of  the  larynx. 

(c)  Thyrotuuiy  {L a vyngu- fissuré). — This  method  should  be 
exclusively  reserved  for  cases  where  the  tumour  is  inside  the 
larynx,  and  particularly  for  neoplasms  seated  on  one  of  the 


36o 


DISEASES  OF  THE  PHARYNX  AND  LARYNX 


vocal  cords.  Tumours  recognized  before  any  infiltration  has 
developed,  or  the  corresponding  arytenoid  is  immobilized, 
alone  have  chances  of  favourable  results  from  operation. 

The  opening  of  the  larynx  may  be  regarded  as  a  benign 
operation,  and  not  endangering  the  life  of  the  patient,  if 


Fig.   196. — Second  Stage  of  Thyrotomy. 

I,  Hyoid  bone;  2,  thyro-hyoid  membrane;  3,  thyroid  cartilage;  4,  crico- 
thyroid membrane;  5,  cricoid  ;  6,  line  of  tracheal  incision. 

performed  according  to  Semon's  rules,  on  which  the  author 
has  made  important  modifications. 

The  volume  of  the  tumour  being  small  enough  not  to 
interfere  with  respiration,  the  patient  is  put  under  chloro- 
form. He  is  then  placed  on  an  inclined  plane,  so  as  to 
avoid  the  flow  of  blood  into  the  air  tract.     Sometimes  it 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     361 

is  sufficient  to  tense  the  neck  backwards,  the  chin  being 
kept  raised  by  an  assistant  holding  an  aseptic  compress. 
The  field  of  operation  having  been  sterilized,  an  incision  is 
made  from  the  hyoid  bone  extending  almost  down  to  the 
sternal  notch,  and  as  much  as  possible  in  the  middle  line. 
The  operator  should  avoid  making  an  oblique  incision,  and, 
to  secure  that  end,  the  assistant  who  holds  the  head  should 
place  his  index-finger  on  the  maxillary  symphysis,  while  the 
other  has  his  at  the  sternal  notch.  The  skin  should  be 
stretched  vertically,  but  not  laterally. 

Beneath  the  skin  and  the  superficial  aponeurosis  there 
are  usually  met  with  in  the  upper  part  the  projection  of  the 
thyroid  cartilage  (pomum  Adami),  and  then  the  thyro-hyoid 
membrane,  whereas  in  the  inferior  part,  if  exactly  in  the 
middle  line,  is  seen  the  muscular  interspace,  through  which 
the  bistoury  is  passed.  At  this  level  the  thyroid  veins  appear, 
and  often  the  arteries  (transverse  and  vertical),  which  are 
necessarily  divided,  and  which  should  be  ligated  before 
the  air  tract  is  opened.  The  thyroid  body,  situate  below, 
should  always  be  resected  medially.  Bleeding,  abundant  at 
first,  is  quickly  stopped  by  direct  compression  and  by  ligature 
of  the  important  vessels.  The  operation  field  being  perfectly 
bloodless  and  the  lips  of  the  wound  being  held  apart,  the 
whole  laryngeal  duct  may  be  seen. 

Before  opening  the  trachea,  it  is  well  to  expose  partially 
the  blades  of  the  thyroid  cartilage  and  to  lay  bare  the  thyro- 
hyoid and  crico-thyroid  membranes,  so  as  to  lay  free  the 
portion  of  the  larynx  to  be  incised.  Hsemostasis  being 
complete  and  the  bloodvessels  ligatured,  tracheotomy  is  then 
performed  below  the  first  or  second  ring  of  the  trachea. 
This  operation  should  be  made  between  two  retractors  slowly 
and  smoothly.  As  one  is  more  or  less  familiar  with  this 
operation,  a  Trendelenburg  or  Hahn's  canula  is  used,  or  even 
an  ordinary  one.  The  patient,  being  partially  awakened, 
may  then  expel  during  the  efforts  of  cough,  which  accompany 
the  introduction  of  the  canula,  the  blood  or  secretions  which 
may  have  fallen  into  the  aerial  tract.  After  the  first  spasms  are 
over,  and  when  the  trachea  is  perfectly  free  from  blood,  the 


302  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

patient  is  again  anaesthetized  through  the  canular  opening. 
If  Trendelenburg's  canula  is  used,  it  is  inflated.  If  Hahn's 
canula  is  used,  we  must  wait  for  about  ten  minutes  for  the 
sponge  surrounding  it  to  become  dilated. 

This  generally  causes  a  fit  of  coughing,  owing  to  the 
pressure  of  the  indiarubber  or  sponge  on  the  walls  of  the 
trachea.  It  is  prudent  in  patients  with  a  narrow  tracheal 
duct  to  dilate  the  trachea  moderately  ;  otherwise  there  might 
occur  an  alarming  syncopal  condition,  with  arrest  of  respira- 
tion. Those  complications  are  not  to  be  feared  with  an 
ordinary  canula.  Chloroform  should  be  administered  at 
a  distance  with  a  special  apparatus  (see  Fig.  197)  and  carefully, 
as  the  patient  absorbs  it  readily.  Besides,  operations  on  the 
larynx  are  liable  to  cause  syncope.  Finally,  it  is  important 
that  the  patient  from  time  to  time  recovers  a  part  of  his 
tracheal  reflexes,  in  order  that  he  may  expel  blood  or  mucus 
from  his  trachea.  By  this  method  the  operator  knows  what 
is  going  on  in  the  air-duct,  and  he  is  able  to  prevent  imme- 
diate or  ulterior  complications  (broncho-pneumonia). 

If  an  ordinary  canula  is  used,  the  crico-thyroid  membrane, 
in  the  first  place,  should  be  incised  from  above  downwards, 
throughout  its  whole  length,  in  the  middle  line,  and  then  a 
strip  of  gauze  soaked  in  the  following  solution  introduced  : 

I^    Hydrochloride  of  adrenalin 

(1:1,000)       ...              ...  15  to  25  drops  iii^xv  to  XXV 

Hydrochloride  of  cocaine       i  gramme  gr.  15 

Distilled  water                 ...  10  grammes  3iiss 

This  will  serve  as  a  tampon  in  the  cricoid  ring.  The 
practitioner  then,  introducing  through  the  opening  of  the 
membrane  the  blade  of  the  curved  scissors  devised  for  that 
purpose  from  below  upwards,  incises  at  one  stroke  the  fibro- 
cartilage  between  the  two  cords.  He  places  a  retractor  on 
each  side  between  the  blades  of  the  cartilage,  and  then 
introduces  into  the  larynx  a  strip  of  gauze  soaked  in  the 
above  solution,  which  also  serves  to  induce  hsemostasis.  If 
the  thyro-hyoid  membrane  is  not  sufficiently  incised  to 
permit  complete  inspection  of  the  larynx,  the  incision  should 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     363 

be  enlarged  vertically  with  scissors.  It  frequently  happens, 
that  the  incision  apparently  made  medially  is  not  exactly 
on  the  medial  line.  A  semi-detached  fragment  of  mucosa 
is  then  seen  hanging  in  the  larynx  and  obstructing  inspection. 
The  patient  bleeds  and  struggles,  and  accordingly  the  bridle 
must  be  rapidly  cut  to  admit  plugging  being  performed,  as 
indicated  above. 

The  most  delicate  part  of  the  operation  is  the  exact 
medial  incision  of  the  thyroid.  This  must  be  performed  in 
one  movement  to  enable  the  blades  of  the  cartilage  to  be 
quickly  separated,  and  rapidly  ensure  hsemostasis.  The 
cricoid  should  not  be  touched.  Shortly  afterwards  two 
retractors  are  inserted  in  the  thyroid,  and  the  cartilaginous 


Fig.   197. — Vessel  for  Administering  Chloroform  through  the 

Canula. 

valves  are  gently  pulled  apart,   like  the  leaves  of  a  book, 
enabling  the  interior  of  the  larynx  to  be  seen. 

The  tumour  then  usually  appears  larger  and  the  insertion 
greater  than  was  shown  by  the  laryngoscopic  mirror 
(Semon).  Before  dealing  with  the  tumour  a  small  plug 
of  sterilized  gauze,  prepared  beforehand,  should  be  inserted 
into  the  ring  of  the  cricoid  or  the  inferior  part  of  the 
opening.  It  should  be  of  the  same  calibre  as  the  trachea, 
and  be  forcibly  stuffed  above  the  canula  and  held  by  a  silk 
thread.  This  inferior  plug  replaces  the  cocainized  strip  of 
gauze  introduced  on  the  incision  of  the  crico-thyroid  mem- 


364 


DISEASES  OF  THE  PHARYNX  AND  LARYNX 


brane,  and  is  intended  to  prevent  the  penetration  of  blood 
into  the  deep  air  tract.  This  method  dispenses  with  the  use 
of  Trendelenburg's  canula  or  its  substitutes. 

A  similar  plug  may  be  placed  advantageously  superiorly 
behind  the  epiglottis  to  prevent  the  saliva  interfering  with  the 
curetting  of  the  larynx. 

Removal  of  the  tumour  should  then   be  made  with  the 


Fig.   198. — Trendelexburg's  Canula. 
The  dotted  lines  represent  the  rubber  portion  when  swollen. 

cutting  forceps,  curved  scissors,  various  curettes,  bistoury, 
etc.  The  base  should  be  cauterized  in  excess  of  the  limits 
of  the  tumour  with  a  thermo-cautery. 

Once  bleeding  is  completely  arrested,  the  blades  of  the 
thyroid  cartilage  should  be  approximated  as  close  as  possible, 
and  maintained  in  that  position  wath  catgut. 


Fig. 


. — Curved  Scissors  for  cutting  the  Thyroid  Cartilage. 
(Moure.) 


The  prelaryngeal  tissues  should  be  gradually  reunited 
layer  by  layer,  the  muscles  being  sutured  with  gut  and  the 
skin  with  horsehair. 

Till  lately  the  operation  w^as  then  ended,  a  plugged  or 
ordinar}^  canula  being  left  in  situ  for  several  days  to  prevent 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     365 

respiratory  disturbance  due  to  post-operative  inflammatory 
œdema.     However,  a  laryngoscopic  examination   made  on 


Fig.    200. — The    Canula   has   been   put   in   Place  ;    the   Black   Stroke 

INDICATES    the  LiNE  OF  THE  ThYROID  InCISION.       In  FIG.  B  THE  CuRVED 

Scissors    for    making    the    Section    are    already    placed    in    the 
Crico-thyroid  Membrane,  which  has  been  cut. 
I,  Hyoid  bone  ;  2,  thyroid  membrane  ;  3,  thyroid  cartilage  (prcjecting  angle)  ; 
4,   crico-thyroid  membrane  ;   5,   cricoid  ;   6  (Fig.    A),  vessel  for  inflating 
the  rubber  portion  of  the  canula;  7  (Fig.  B),  line  of  the  thyroid  incision. 

the  same  evening  or  the  day  after  has  enabled  the  author  to 
verify  that  the  laryngeal  orifice  was  still  adequate  to  permit 


366 


DISEASES  OF  THE  PHARYNX  AND  LARYNX 


of  the  entrance  of  air  into  the  air  tract,  and  he  has 
practised  in  his  later  operations  complete  suture  of  the  laryngo- 
tracheal tract  from  above  downwards. 

The  author,  from  motives  of  prudence,  has  nevertheless 
left  at  the  inferior  part  of  the  wound  at  the  level  of  the  tracheal 
opening  a  small  unsutured  wound  of  the  skin  and  subjacent 
tissue,  to  avoid  emphysema,  which  is  apt  to  occur  during 
vomiting,  or  from  cough  following  operation.  The  patient 
should  be  placed  under  supervision  for  forty-eight  hours, 
and  the  canula  rapidly  replaced  if  respiratory  disturbances 
endanger  life. 

It  must  be  recollected  that  the  removal  of  the  tumour, 
on  the  one  hand,  with  tearing  of  the  laryngeal  mucosa  and 
thermo- cauterization  on  the  other,  not  only  produce  peri- 
pheral   œdematous    infiltration,   but    also   the    formation   of 


Fig.  20I. — Steel  Retractor  (Nickel-plated). 

a  pseudo-membranous  layer,  and  sometimes  contraction  of 
the  opposite  cord,  thereby  producing  respiratory  stenosis.  The 
latter,  however,  never  necessitates  the  replacing  of  the  canula. 

This  method  hastens  cure  and  avoids  broncho-pulmonary 
complications. 

The  author  thinks,  that  transverse  laryngotomy,  either 
above  or  below  the  hyoid,  does  not  allow  free  access. 

It  offers  no  advantage  over  medial  section  of  the  thyroid. 
He  is  of  opinion,  that  abstention  from  tracheotomy  is 
dangerous,  as  it  is  difficult  during  an  operation  on  a  bleeding 
larynx  to  chloroform  the  patient  by  that  route,  when  penetra- 
tion of  blood  into  the  air  tract  cannot  be  prevented  ;  and 
that  is  a  grave  accident. 

{d)  Partial  or  Total  Extirpation  of  the  Larynx. — This  method 
has  lately  given  encouraging  results. 

If  during  thyrotomy  a  malignant  degeneration  of  the  thyroid 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     367 

cartilage  is  observed — e.g.,  of  one  of  the  blades  or  a  portion 
of  it — the  affected  region  should  be  resected  beyond  its  limits, 
and  if  need  be  hemilaryngectomy  performed.  An  attempt 
should  then  be  made  to  reconstitute  a  laryngeal  channel,  either 


Fig.  202. — Last  Stage  of  the  Operation  ;    the  Larynx  is_Opened, 
AND  THE  Thyroid  Valves  kept  Apart. 

I,  Hyoid  bone;  2,  thyro-hyoid  membrane,  partly  cut  and  held  apart  ; 
3,  thyroid  valve  folded  over  ;  4,  covered  crico  -  thyroid  membrane  ; 
5,  cricoid  ;  6,  left  ventricular  band  held  open  ;  7,  ventricle  of  Morgagni  ; 
8,  left  vocal  cord  ;  9,  tumour  inserted  on  the  right  vocal  cord. 

by  suturing  the  remaining  portions  of  the  thyroid,  or  if  half 
of  the  organ  has  been  removed,  by  letting  the  wound  cicatrize. 
As  a  general  rule,  the  remaining  side  of  the  larynx  continues 
to  act  as  before,  while  the  other  is  replaced  by  a  cicatricial 
fibrous  tissue. 


368  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

The  author  has  had  the  opportunity  of  seeing  the  tracheal 
canula  dispensed  with  some  time  afterwards,  the  patient 
being  able  to  breathe  by  the  new  cicatricial  channel.  At 
any  time  if  respiratory  embarrassment  takes  place,  it  is  easy 
bv  the  help  of  a  dilator  to  keep  the  wound  open. 

If  the  whole  of  the  thyroid  is  invaded,  intervention  is  open 
to  discussion,  not  because  of  the  operation,  but  of  its  unsatis- 
factory results,  as  most  cases  prove  fatal  within  two  or  three 
years — some  from  recurrences,  others  from  intercurrent  affec- 
tions (broncho-pneumonia,  cerebral  haemorrhage,  etc.).  This 
mortality  may  be  attributed  to  the  unfavourable  conditions  of 
operation,  for  the  neoplasm  may  not  only  have  invaded  the 
larynx,  but  also  the  neighbouring  parts  (oesophagus,  base  of 
the  tongue,  etc.j,  often  even  the  glands  of  the  region.  The 
operation,  to  have  any  real  chance  of  success,  should  be 
performed  when  the  tumour  is  still  encapsuled  in  the  larynx. 
Once  the  operation  is  decided  on  and  accepted  by  the  patient, 
the  best  method  of  procedure  is  manifestly  that  recommended 
by  Périer,  which  consists  in  making  in  front  of  the  neck  a 
T-shaped  incision — one  cut  being  in  the  middle  line,  as  in 
thyrotomy,  the  other  transverse  over  the  hyoid.  Those 
incisions  should  penetrate  to  the  laryngeal  cartilage.  The 
larynx  being  then  regarded  as  a  true  tumour,  its  external 
surface  must  be  laid  bare  by  reflecting  the  muscles  to  the 
level  of  the  inferior  constrictors  of  the  pharynx.  The  larynx 
thus  freed  is  only  connected  posteriorly  with  the  pharyngo- 
œsophageal  mucosa,  and  below  with  the  trachea,  which  has 
not  yet  been  opened.  The  trachea  should  then  be  detached 
from  the  œsophagus  by  means  of  the  grooved  director  and 
the  finger  ;  a  thread  passed  through  the  trachea  to  draw 
the  latter  forward  is  very  useful. 

Bleeding  having  been  arrested  during  the  operation,  the 
first  tracheal  ring  below  the  cricoid  cartilage  is  now  cut,  and 
the  tracheal  tube  drawn  forward,  so  as  to  introduce  internally 
a  special  canula  of  large  calibre.  The  administration  of 
chloroform  is  now  continued  through  the  external  orifice  of 
the  canula,  while  extirpation  of  the  larynx  is  being  com- 
pleted.    The  larynx  should  be  separated  posteriorly  from  the 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     369 

pharyngeal  mucosa,  and  laterally  from  the  great  cornua  of  the 
hyoid  bone,  and,  if  need  be,  from  the  epiglottis  at  its 
base,  should  it  be  necessary  to  remove  the  operculum.  The 
operation  is  finished  by  suturing  the  opened  tracheal  ring 


Fig.  203.— Appearance  of  a  Patient  affected  with  Cancerous  Relapse 
AFTER  Extirpation  of  the  Larynx.     (Drawn  from  Nature.) 

to  the  inferior  part  of  the  wound,  in  order  to  bring  it  com- 
pletely to  the  surface  of  the  neck.  Great  care  must  betaken 
to  leave  in  the  trachea  a  canula  to  ensure  respiration. 

The  larynx  being  removed,  an  œsophageal  tube  is  placed 

24 


370  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

in  the  stomach,  introduced  through  one  of  the  nostrils, 
and  an  attempt  is  then  made  to  suture  the  anterior  wall 
of  the  œsophagus  to  the  inferior  portion  of  the  thyro-hyoid 
membrane,  or,  if  the  hyoid  bone  has  been  removed,  to 
the  inferior  portion  of  the  wound  with  the  base  of  the 
tongue.  This  procedure  has  the  advantage  of  completely 
separating  the  laryngeal  wound  from  the  buccal  cavity,  and 
consequently  of  protecting  it  from  secondary  infection.  Com- 
plete union  of  the  wound  situate  above  the  canula  can  be 
brought  about  by  merely  introducing  a  drain,  in  order  to 
facilitate  the  escape  of  fluids  that  are  formed  almost  always 
after  the  operation,  and  also  to  prevent  the  secondary  infec- 
tion, which  may  supervene  by  the  very  rapid  destruction  of  the 
sutures  which  bind  the  oesophagus  to  the  floor  of  the  mouth. 

This  method  has  the  sole  inconvenience  of  preventing 
laryngeal  prothesis,  but  we  know  unfortunately  that  the 
latter  has  not  given  good  results.  Moreover,  Dr.  Gluck,  of 
Berlin,  spoke  very  favourably  at  the  International  Congress 
of  Medicine  at  Paris  in  igoo  of  a  means  of  rhino-tracheal 
prothesis,  which  enables  the  patient  to  speak  in  a  loud  tone. 
He  obtained  this  result  by  placing  a  phonatory  tube  in  the 
tracheal  orifice  and  another  in  the  patient's  nose,  and  success- 
fully utilized  this  apparatus,  in  spite  of  the  absence  of  com- 
munication between  the  trachea  and  the  mouth. 

In  cases  where  the  operation  is  performed  during  the  stage 
of  asphyxia,  when  laryngeal  stenosis  is  complete,  and  when 
tracheotomy  is  compulsory,  or  when  the  patient  already  wears 
a  canula,  the  operative  conditions  are  somewhat  different. 

It  is  expedient,  after  having  made  the  preceding  T-shaped 
incision  on  the  skin  and  tissues  of  the  neck,  so  as  to  lay  bare 
the  organ,  to  detach  at  first  the  larynx  laterally,  carefully 
avoiding  the  introduction  of  blood  into  the  air  tract.  For 
that  purpose  Trendelenburg's  canula  is  often  necessary. 
This  requires  careful  attention.  As  soon  as  the  larynx  is 
almost  free,  the  tracheal  end  should  be  rapidly  cut,  and  the 
operation  proceed  on  the  lines  referred  to  above. 

Occasionally  a  wide  fistula  may  remain  in  front  of  the 
neck  in  place  of  the  larynx,  communicating  freely  with  the 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     371 

base  of  the  tongue  and  the  pharynx.  To  close  this  fistula, 
Dr.  Gluck  has  designed  an  autoplastic  operation,  which 
the  author  has  seen  employed  by  him  with  good  results. 
It  consists  in  making  on  the  anterior  portion  of  the  neck 
two   cutaneous  flaps,   by   means   of  two   parallel   transverse 


incisions  on  the  same  horizontal  plane,  ABCD  and  EFGH, 
which  pivot,  the  first  round  the  axis  AD,  and  the  second 
round  the  axis  EH.  The  flap  EFGH,  the  greater,  is  raised; 
while  the  flap  ABCD,  the  smaller,  is  turned  over  on  itself,  the 
axis  AD  remaining  fixed,  the  side  BC  joining  at  B'C',  where 
it  is  attached,  the  cutaneous  surface  being  turned  backwards. 

24 — 2 


372  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

The  raw  surface,  AB'C'D,  is  covered  partly  by  the  raw 
surface  of  the  flap  EFGH.  The  flap  EFGH  is  then  restored 
to  its  former  position,  and  in  consequence  of  the  elasticity 
of  the  tissues,  FG  comes  to  occupy  a  position,  F"G",  neigh- 
bouring to  BC.  By  dissecting  a  little  beyond  this  flap  perfect 
union  can  be  obtained,  which  may  be  maintained  by  suturing. 

It  follows  from  this  autoplasty,  that  the  space  AFDG  is 
covered  with  a  double  cutaneous  surface,  one  facing  the 
organs  primarily  removed,  the  other  re-establishing  the  con- 
tinuity of  the  cervical  integuments. 

The  sole  inconvenience  of  this  method  is,  that  the  part  of 
the  skin  turned  back  from  the  side  of  the  pharynx  is  often 
covered  with  hair  which  grows  at  the  base  of  the  tongue. 
This  necessitates  epilation  from  time  to  time.  However, 
when  this  epidermis  has  remained  long  enough  in  contact 
with  the  pharyngeal  wall — a  warm  and  humid  medium — 
the  epithelium  becomes  quickly  modified,  and  resembles  a 
rather  thick  mucous  membrane. 

Foreign  Bodies  in  the  Larynx  and  Air  Tract. 

Foreign  bodies  in  the  larynx  and  air  tract  are  frequently 
seen.  We  may  divide  them  into  liquid  and  solid.  In 
the  first  class  are  ordinary  beverages,  introduced  into  the 
air  tract  during  deglutition,  or  blood  from  the  lungs,  the 
bronchi,  or  a  tracheal  wound.  Solid  bodies  penetrate  by 
the  mouth,  or  externally  after  a  traumatism  (bullets,  etc.). 

The  introduction  of  bodies  by  the  natural  tract  may  be 
the  result  of  disturbances  of  sensibility,  due  to  central  lesions 
(old  men,  lunatics),  or  to  peripheral  paralysis  (diphtheria). 

The  author  cannot  admit,  that  destruction  or  morbid  con- 
ditions of  the  epiglottis  are  a  frequent  cause  of  the  penetration 
of  foreign  bodies  into  the  air  tract,  for  he  has  seen  patients 
not  at  all  inconvenienced  by  the  loss  of  the  glottic  operculum. 

Foreign  bodies  may  even  penetrate  into  the  larynx  or  the 
trachea  during  the  administration  of  chloroform  or  ether  ; 
accordingly,  it  is  advisable  to  examine  the  mouth  before 
administering  an  ansesthetic.  Most  frequently  this  accident 
occurs  unexpectedly.     During  a  fit  of  laughter,  or  in  conse- 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     373 

quence  of  a  fright,  a  short,  deep  inspiration  draws  the  foreign 
body  from  the  buccal  cavity  into  the  air  tract.  The  same 
may  happen  during  sleep,  when  children  or  adults  have  gone 
to  bed  with  an  object  in  their  mouth. 

In  countries  where  vulcanized  or  gutta-percha  canulse  are 
used,  it  sometimes  happens  that  after  tracheotomy  fragments 
of  these  latter  become  detached,  and  penetrate  into  the 
trachea  or  one  of  the  bronchi. 

During  deglutition  sharp  bodies  are  often  arrested  at  the 
entrance  of  the  larynx  (needles,  pins,  etc.). 

Finally,  foreign  bodies  may  come  from  the  œsophagus 
through  ulceration  of  its  walls,  or  from  suppuration  of  a 
bronchial  gland.     Similarly,  an  object  introduced  into  the 


Fig.    205.  —  Leech    attached    to 
THE  Left  Vocal  Cord. 


Fig.  2o5. — Same  Larynx  after  the 
Extraction  of  the  Leech. 


nasal  fossae  or  the  back  of  the  nose  may  fall  into  the  larynx 
during  a  movement  of  inspiration,  or  be  carelessly  pushed 
down  by  the  hand  of  the  surgeon.  In  hot  countries  leeches 
are  occasionally  seen  in  the  larynx  where  the  individual, 
being  thirsty,  has  drunk  greedily  from  a  stream. 

Solis-Cohen  has  recorded  the  fact  of  patients  having 
swallowed  their  epiglottis.  The  author  himself  has  seen  a 
fatal  case  of  that.  In  this  way  Riihle  explains  several 
sudden  deaths  occurring  at  table.  Fletcher- Ingalls  has 
recorded  in  1881  the  case  of  a  patient  who  had  swallowed 
his  tongue.  These  cases  are,  however,  rare  enough  to  be 
quoted  only  as  curiosities. 

Symptoms.  —  The  symptoms  caused  by  the  presence  of 
foreign  bodies  in  the  air  tract  vary  according  to  their  bulk, 


374  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

form,  and  position.  If  the  dimensions  are  large  enough 
completely  and_  suddenly  to  obstruct  the  larynx,  death  may 
be  immediate.  These  instances  are  common  in  asylums 
among  old  men  and  lunatics. 

Oblong  and  smooth  bodies  more  easily  penetrate,  and 
may  become  enclosed  in  the  ventricle  of  Morgagni,  remain 
between  the  two  cords,  or  even  descend  into  the  trachea  as 
far  as  its  bifurcation.  If  they  penetrate  further,  they  usually 
lie  in  the  right  bronchus. 

The  first  symptom  of  a  foreign  body  in  the  air  passages 
is  a  fit  of  convulsive,  spasmodic,  very  violent,  and  almost 
characteristic  cough.     Gradually  this  fit  abates  during  a  lapse 


Fig.  207. — Bent  Hairpin  stuck  in  the  Left  Ventricle,  and 
Removed  by  the  Natural  Tract. 

of  time,  varying  with  the  position  of  the  object  and  its 
volume,  and  according  to  the  fixation  of  the  foreign  body  in 
the  air  tract  or  to  its  mobility. 

In  the  latter  case  an  attack  of  convulsive  coughing  pro- 
jects the  body  suddenly  towards  the  cords,  which  close 
immediately  to  hinder  its  egress.  It  then  produces  a 
characteristic  slapping  sound.  The  intervals  between  each 
spasm  var}',  some  patients  having  onsets  twice  or  thrice 
daily,  while  others  experience  suftbcative  attacks,  renewed 
on  the  least  movement. 

Pain  is  often  absent.  \\'hen  it  does  exist,  it  is  sometimes 
localized  at  the  level  of  the  larynx  or  around  the  cricoid. 

The    voice    may    be    husky,    bitonal,    aphonic,    and    even 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     375 

'  choked,'  according  as  the  foreign  body  is  situate  in  the 
subglottic  region  or  between  the  vocal  cords.  Frequently 
the  voice  assumes  a  raucous  and  croup-like  timbre. 

Vocal  disturbances  are  absent,  when  the  body  has  pene- 
trated below  the  larynx. 

The  characteristics  of  the  cough  are  equally  variable.  It 
is  usually  convulsive,  suffocative,  and,  like  the  voice,  rau- 
cous and  croup-like.  The  latter  is,  so  to  speak,  characteristic, 
especially  when  accompanied  by  the  valve-like  sound,  due  to 
the  impact  of  the  foreign  body  on  the  glottic  orifice,  which  is 
closed  by  the  efforts  of  coughing.  Very  often  a  child  is  made 
to  cough  so  that  this  symptom  may  be  perceived. 


Fig.  208. — Piece  of  Glass  at  the  Entrance  to  the  Larynx. 

Appearance  of  the  foreign  body  seen  from  above  and  after 
its  extraction. 


The  expectoration  may  be  mucoid,  as  in  asthma.  It  is 
often  muco-purulent,  or  even  streaked  with  blood,  if  the 
foreign  body  has  lodged  for  some  time  in  the  air  passage,  and 
caused  irritation  of  the  neighbouring  parts.  In  the  case  of 
leeches,  parasites,  or  living  insects,  the  expectoration  is  bloody. 

Generally  speaking,  percussion  affords  no  indication,  but 
it  is  often  possible,  on  palpation  of  the  anterior  surface  of 
the  trachea,  to  feel  the  body  move  under  the  finger  at  the 
moment  of  coughing. 

Auscultation  assists  diagnosis.  Sounds  produced  by  their 
movements  and  the  flapping  noise  characteristic  of  mobile 
bodies  are  thereby  perceptible,  as  well  as  evidences  of  a 
bronchial  constriction  or  obstruction. 

Direct  examination  is  often  inadequate.      Nevertheless,  if 


376  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

the  object  is  in  the  larynx,  direct  examination  is  the  sole 
means  of  determining  its  nature,  its  form,  and  its  size.  If, 
however,  it  is  situate  below  the  larynx,  examination  is  more 
difficult,  and  may  prove  negative  in  children,  who  are  difficult 
to  examine.  In  such  cases  the  history  of  the  above  symptoms 
may  often  lead  us  to  conclude,  that  the  foreign  body  has 
passed  below  the  larynx. 

Radioscopy,  or  even  radiography,  may  also  be  valuable  in 
such  circumstances.  It  is  thus  often  possible  to  perceive  a 
foreign  body,  even  a  seed,  in  the  interior  of  the  air  tract,  and 
consequently  to  determine  its  position.  Direct  tracheoscopy, 
after  Killian's  method,  is  also  a  valuable  means  for  exploration 
and  extraction. 

The  author  thinks,  that  digital  palpation  is  useless  and 
often  dangerous,  as  instead  of  being  of  assistance  in  recog- 
nizing a  foreign  body  introduced  into  the  upper  air  tract,  it 
tends  to  make  an  object  situate  at  the  entrance  of  the  larynx 
penetrate  more  deeply. 

Course, — Foreign  bodies  are  most  frequently  expelled  spon- 
taneously, as  at  the  moment  of  their  penetration  into  the 
air  tract  the  vocal  cords,  contracting  energetically,  prevent 
their  deeper  ingress.  Once  introduced  into  the  larynx  or 
below  it,  they  behave  according  to  their  form  and  nature. 
If  they  are  sharp  and  pointed  (needles),  they  can  migrate 
across  the  tissues.  Thus,  certain  sharp  objects  can  traverse 
the  thorax,  and  appear  on  the  side  of  the  chest  or  in  other 
regions. 

Dî'iration.  —  The  persistence  of  foreign  bodies  in  the  air 
tract,  when  death  does  not  immediately  follow  their  intro- 
duction, is  variable.  Certain  seeds  are  liable  to  soften,  be 
even  dissolved  and  gradually  eliminated  with  the  tracheal  or 
bronchial  mucus.  At  other  times  suppuration  occurs,  de- 
taching the  foreign  body,  and  facilitating  its  expulsion  after 
a  lapse  of  time.  Sometimes  it  becomes  fixed  in  the  air  tract, 
and  remains  for  months  and  years. 

In  other  cases,  however,  it  finally  causes  death  through 
sepsis.  We  have  thus  been  able  by  autopsy  of  patients  treated 
as  tuberculous  to  find  in  the  bronchi  various  foreisin  bodies. 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     377 

Although  patients  have  hved  six,  eight,  or  even  ten  years 
with  foreign  bodies  in  their  air  passages,  it  must,  however,  be 
confessed,  that  in  general  local  infections  are  produced,  which 
end  sooner  or  later  in  death,  either  by  suffocation  or  in  con- 
sequence of  acute  or  chronic  pulmonary  lesions,  or  of  abscess 
of  the  neighbouring  parts. 

Complications. — The  most  frequent  one  is  emphysema  due 
to  infiltration  of  air.  The  convulsive  coughing  favours  the 
appearance  of  this  complication.  The  purulent  matter  may 
produce  asphyxia  and  septic  complications,  by  penetrating 
into  the  mediastinum. 

Tracheal  ulceration  is  also  observed,  as  well  as  ulceration 
of  the  larger  bronchi,  or  caseous  pneumonia  simulating  tuber- 
culosis. 

Prognosis  varies  according  to  the  position  of  the  offending 
bod}^  its  nature,  its  size,  and  the  age  of  the  patient. 

Diagnosis.  —  The  first  point  is  to  find  out  if  the  foreign 
body  is  actually  present,  as  many  patients  come  in  the  false 
behef  that  they  have  something  in  their  larynx  or  trachea. 
When  it  exists,  its  nature  and  position  must  be  determined. 
If  the  foreign  body  is  lodged  in  the  larynx,  the  laryngo- 
scope indicates  its  presence,  its  form,  its  bulk,  and  its 
situation. 

If,  on  the  contrary,  it  has  passed  below  the  cords,  and 
if,  for  some  reason  (intractability  of  the  patient,  peripheral 
inflammation,  etc.),  laryngoscopic  and  tracheoscopic  examina- 
tion are  not  applicable,  recourse  must  be  had  to  the  history 
for  information.  This  will  show  the  abruptness  of  the 
attack,  as  in  the  case  of  a  child  playing  with  an  object  in 
its  mouth  and  being  seized  with  violent  suffocation  and 
impending  asphyxia.  These  onsets  are  repeated  in  the 
night-tim.e,  according  as  the  object  is  more  or  less  bulky 
and  movable.  A  comparative  calm  exists  between  the 
attacks,  which  often  deceives  the  parents  and  sometimes  the 
doctor.  The  cough  is  usually  raucous,  convulsive,  su-.o- 
cative,  and  is  sometimes  sonorous.  The  '  slapping  sound  ' 
is  present,  and  palpation  over  the  anterior  wall  of  the  trachea 
reveals  the  presence  of  the  foreign  body. 


378  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

Croup  is  readily  recognized  by  direct  inspection,  or  in 
any  case  by  the  laryngeal  mirror. 

Sometimes  foreign  bodies  show  none  of  the  foregoing 
symptoms.  Diagnosis  is  then  difficult,  if  the  patient  or  his 
friends  have  forgotten  the  possibility  of  the  introduction 
of  the  body  into  the  air  tract. 

The  radioscope  and  the  radiograph  afford  valuable  in- 
formation in  cases  of  this  kind. 

Treatment. — An  emetic  or  titillation  of  the  pharyngeal 
cavity  with  a  feather  is  prescribed,  but  those  methods  are 
unsatisfactory,  and  only  serve  to  displace  the  body  and 
produce  a  spasm  of  rapid  asphyxia,  or  cause  the  body  to 
penetrate  deeper  into  the  respiratory  tract.  It  is  for  similar 
reasons  dangerous  to  attempt  extraction  with  the  forceps 
alone  or  otherwise. 

In  a  case  of  exigency  the  patient  should  be  placed  head 
downwards,  or  laid  on  an  inclined  plane,  and  sharp  succussion 
applied.     This  method  may  succeed  with  heavy  bodies. 

Laryngeal  reflexes  and  glottic  spasms,  preventing  the  egress 
of  foreign  bodies  situate  below  the  cords,  may  be  avoided  by 
chloroforming  the  patient. 

Should  those  methods  fail,  recourse  must  be  had  to 
extraction,  and  here  the  methods  of  operation  vary  according 
to  the  nature  of  the  body  introduced  and  the  depth  at  which 
it  is  situate.  Extraction  by  the  natural  tract  may  be  tried, 
if  the  body  is  at  the  laryngeal  orifice,  in  the  vestibular  region, 
and  the  patient  lends  himself  to  laryngoscopic  operation. 
Favourable  results  may  be  expected,  except  in  the  case  of 
young  children. 

Owing  to  laryngoscopy,  we  can  nowadays  quote  hundreds 
of  bodies  extracted  by  the  mouth. 

Bodies,  whose  nature  and  position  have  been  determined 
beforehand,  are  readily  removed  by  an  experienced  operator, 
the  larynx  being  anaesthetized  with  cocaine  (i  in  lo),  and 
he  availing  himself  of  the  numerous  modern  laryngeal 
instruments. 

If  the  foreign  body  in  the  air  tract  has  penetrated  deeply 
into  the  larynx,  or  if  it  is  firmly  embedded  in  the  ventricles 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     379 

of  Morgagni  or  between  the  cords,  the  method  of  extraction 
varies  according  to  the  object.  Extraction  by  the  natural 
passages  may  be  absolutely  impossible,  as  the  body  may 
be  firmly  fixed  and  even  embedded  in  the  laryngeal  walls. 
Extirpation  by  the  external  tract  should  in  such  cases  be 
unhesitatingly  practised  by  opening  the  thyroid  cartilage 
mesially.  At  a  pinch  we  might  try  extraction  by  simple 
incision  of  the  crico-thyroid  or  thyro-hyoid  mucosa,  depend- 
ing on  the  position  of  the  foreign  body  ;  but  it  is  clear,  that 
thyrotomy  (mesial  laryngo-fissure)  permits  of  a  safer  opera- 
tion in  the  larynx,  and  even  above  and  below  that  organ. 
Thyrotomy  may  be  practised,  according  to  the  circumstances 
and  the  custom  of  the  operator,  with  or  without  preliminary 


Fig.  209. — Corset-latch  embedded  in  the  Larynx, 

REMOVED    BY    ThYROTOMY. 

Appearance  of  the  foreign  body  in  the  larynx  and  after  its  removal. 

tracheotomy.  Generally,  and  in  children  especially,  the 
vertical  and  medial  incisions  of  the  thyroid  cartilage  and 
of  the  overlying  tissues  give  rise  to  little  hsemorrhage,  and 
thus  the  tracheal  tube  need  not  be  opened.  However,  if 
symptoms  of  asphyxia  exist,  tracheotomy  should  first  be 
performed,  then  thyrotomy. 

Once  the  foreign  body  is  removed,  the  air  tract  and  the 
pretracheal  tissues  should  be  sutured  with  catgut  and  the 
skin  reunited  with  horsehair.  A  rapid  cure  ensues  in  a  few 
days. 

If  the  foreign  body  is  situate  below  the  larynx,  the  indica- 
tion is  generally  more  defined.  Although  some  very  skilled 
operators  have  removed  per  vins  naturales  foreign  bodies 
from  the  trachea,  and  even  from  the  bronchi,  those  cases 


38o  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

are  exceptional,  especially  when  the  body  is  smooth  and 
easily  eludes  the  grasp  of  the  forceps  (kernel,  seeds,  etc.)- 
In  this  case  the  trachea  must  be  opened  below  the  cricoid. 
The  best  method  to  obtain  a  clear  operative  field  is  to 
proceed  slowly,  making  in  the  pretracheal  tissues  a  long 
incision,  laying  bare  the  trachea  for  at  least  2  or  3  centimetres. 
Before  opening  the  air  tract,  the  operator  should  ascertain 
that  all  bleeding  has  ceased,  that  the  sensibility  of  the 
mucous  membrane  is  not  completely  destroyed  by  narcosis, 
as  tracheal  reflexes  may  facilitate  the  expulsion  of  the 
foreign  body.  Immediately  the  trachea  is  opened,  instead 
of  placing  in  the  opening  the  ordinary  dilator,  whose 
branches  are  thick  and  project  into  the  incision,  it  is 
preferable  to  place  on  each  side  two  blunt  hooks,  or  two 
hairpins  bent  at  their  rounded  end.  These  dilators  intro- 
duced between  the  lips  of  the  tracheal  wound  should  be 
gently  drawn  apart  so  as  to  favour  the  egress  of  the  foreign 
body,  which  is  often  expelled  during  the  onset  of  coughing 
which  follows  the  opening  of  the  air  tract.  At  other  times 
the  object  may  show  itself  at  the  orifice  of  the  wound,  then 
become  aspired,  and  while  being  tossed  rapidly  upwards  and 
downwards,  it  must  be  seized  and  fixed  on  the  posterior 
wall  before  extraction  can  take  place.  These  different 
manoeuvres  should  be  made  with  forceps,  a  blunt  hook,  a 
bent  curette,  or  any  other  suitable  instrument.  The  opera- 
tion over,  the  author  highl}^  recommends  immediate  reunion 
of  the  tracheal  tube,  and  also  complete  suturing  of  the  lips 
of  the  wound  with  catgut  ;  the  pretracheal  tissues  should 
also  be  brought  together  with  the  same  material  and  the  skin 
with  horsehair. 

In  cases  where  the  foreign  body  cannot  be  expelled  or 
extracted  during  the  operation  on  account  of  its  being  deeply 
fixed  towards  the  bronchial  spur  or  in  one  of  the  bronchi, 
inspection  can  be  made  with  Killian's  tracheoscopic  tube, 
and  the  object  extracted  by  a  special  forceps. 

If  these  manœuvres  prove  unsuccessful,  the  tracheal  wound 
should  be  left  open  and  a  canula  inserted,  with  a  view  to 
making  other  attempts  on  the  same  day  or  afterwards. 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     381 

It  is  even  possible  (Killian)  to  explore  for  foreign  bodies 
situate  in  a  large  bronchus,  or  even  in  a  bronchus  of  the 
second  or  third  division,  by  superior  tracheoscopy  and 
bronchoscopy  performed  during  chloroform  narcosis. 

Finally,  if  the  body  is  metallic,  strong  electro-magnets 
may  extract  it.  To  accomplish  this  the  magnet  should 
be  placed  before  the  tracheal  opening,  or  a  piece  of  curved 
magnetized  iron  be  introduced  by  the  orifice  in  the  direction 
of  the  foreign  body.  This  method  is  worthy  of  serious 
consideration.  A  metallic  object  deeply  seated  in  the  air 
tract  may  be  detached  thus  through  the  thoracic  wall,  and 
the  body  be  directed  towards  the  large  bronchi,  or  even  the 
trachea,  whence  it  may  be  easily  extracted. 

The  author  recommends  the  most  prompt  intervention 
that  is  possible  for  foreign  bodies  in  the  air  tract,  as  they 
constitute  a  continual  source  of  danger.  It  is  always  better 
to  operate  before  complications  appear. 

Laryngitis  associated  witii  tlie  Eruptive  Fevers. 

Attention  is  not  usually  directed  in  practice  to  the  larynx 
in  eruptive  fevers,  unless  respiratory  stenosis  is  sufficiently 
pronounced.  Affections  of  this  organ  are  presumed,  rather 
than  confirmed,  by  direct  examination.  The  author  thinks 
this  negligence  is  most  reprehensible,  as  certain  eruptive 
fevers  leave  after  them  grave  and  incurable  disorders,  which 
might  have  been  prevented  by  proper  treatment. 

Rubeolar  Laryngitis. 

Functional  disturbances  are  generally  very  slightly  marked 
in  the  prodromal  period,  and  merely  consist  of  a  slight 
huskiness  or  extreme  harshness  of  the  voice.  Coughing 
assumes  an  acute  dissonant  timbre,  especially  when  the 
eruption  begins  to  appear.  Attacks  of  suffocation  and  true 
stridulous  laryngitis,  probable  consequences  of  peritracheal 
adenopathy  during  the  eruption,  are  also  observed.  At 
this  period  respiratory  disorders  may  be  seen,  due  either  to 
arytenoid  or  glottic  infiltration,  or  to  the  more  or  less 
complete   immobility    of    the    crico-arytenoid   articulations. 


382  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

Dyspnœa  may  equally  be  the  result  of  recurrent  compression 
by  peritracheal  glands  more  or  less  swollen. 

During  convalescence  the  functional  disturbances  are 
almost  the  same  as  those  of  the  eruptive  stage,  except  that 
when  the  larynx  is  affected,  the  lesions  are  usually  more 
important.  True  membranous  laryngitis  (croup)  has  been 
observed  grafted  on  a  primary  catarrhal  condition  ;  never- 
theless, this  mode  of  termination  of  rubeolar  laryngitis 
varies  according  to  the  epidemics.  Gottstein  formerly  ex- 
pressed the  opinion,  that  measles  provoked  a  predisposition 
to  the  localization  of  the  diphtheritic  processes  in  the  larynx. 
Lori  admits  that  the  predisposition  to  croup  in  course  of 
measles  is  hereditary,  as  he  had  noticed  that  children  of  the 
same  family,  having  measles  at  distant  intervals,  were  on 
each  occasion  attacked  by  this  complication.  In  a  similar 
way,  with  several  years'  interval,  each  member  of  a  family 
succumbed  to  diphtheria  consequent  on  this  eruptive  fever. 
However,  other  authors  have  not  made  analogous  remarks. 

Laryngoscopic  Examination. — It  is  very  rare  in  the  pro- 
dromal stage  to  have  the  opportunity  of  examining  the  vocal 
mucosa,  for  parents  believe  that  their  children  have  merely 
caught  cold,  and  seldom  consult  the  doctor. 

In  rare  cases,  when  the  author  examined  the  laryngeal 
mucosa,  he  has  met  with  a  slightly  diffuse  redness,  with 
some  disturbances  of  muscular  asynergia,  suggesting  simple 
catarrhal  laryngitis. 

Laryngoscopic  examination  at  the  eruptive  period  shows 
the  laryngeal  mucous  membrane  uniformly  red,  and  with  a 
strong  light  it  is  even  possible  (Gerhardt)  to  see  a  reddish 
stippling,  analogous'  to  that  seen  on  the  pharyngeal  cavity 
and  the  soft  palate  of  children  affected  with  measles. 
According  to  Gottstein,  tru,e  papulae  appear.  Sometimes 
those  are  thick  and  sufficiently  confluent  to  form  on  the 
mucosa  of  the  larynx  elevated  lines  of  a  dark  red 
colour,  serpiginous,  and  covered  here  and  there  with  small 
nodules. 

In  some  rare  cases  small  erosions  are  found  either  on 
the  vocal  cords,   the  ventricular  mucosa,  or  the  arytenoid 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     383 

eminences,  accompanied  always  by  œdematous  infiltration 
of  the  aryepiglottic  folds  and  the  arytenoid  region. 

When  laryngitis  supervenes  during  convalescence,  a 
noticeable  exudation  is  seen  on  the  surface  of  the  pharynx, 
the  larynx,  and  the  trachea,  the  mucosa  assuming  a  velvety 
appearance,  usually  dark  red,  with  small  ecchymoses,  erosions, 
and  ulcers,  and  situated  on  the  posterior  portion  of  the  vocal 
cords  or  the  extremity  of  the  cartilages  of  Santorini.  The 
ulcer  is  of  irregular  form,  with  indented  edges,  surrounded 
by  a  more  or  less  considerable  zone  of  infiltration,  according 
to  its  extent  and  depth.  It  originates  in  an  alteration  of  the 
closed  follicles  of  the  laryngeal  mucosa.  In  very  rare  cases 
abscesses  of  the  ventricular  bands  or  arytenoid  eminences 
occur  with  oedema  of  the  neighbouring  parts. 

On  several  occasions  the  author  has  observed  the  existence 
of  subglottic  infiltration,  with  partial  immobility  of  the  ar}'- 
tenoids  in  children  affected  with  stridulant  and  stertorous 
breathing.  This  subglottic  laryngitis  appears  to  the  author 
to  be  a  frequent  complication  in  certain  epidemics. 

Crico-arytenoid  arthritis  and  pseudo-membranous  laryn- 
gitis are  easily  diagnosed. 

Diagnosis  of  the  laryngeal  disturbances  of  measles  is  easy, 
especially  during  the  course  of  the  disease.  When  the 
eruption  has  not  appeared,  the  most  we  can  do  is  to  think 
of  a  simple  stridulous  laryngitis  ;  but  it  is  sufficient  to  recall 
that  this  affection  supervenes  in  the  night-time,  while  in 
rubeolar  laryngitis  the  onsets  are  diurnal  as  well  as  noc- 
turnal, and,  besides,  they  are  frequently  continuous. 

Hyperasmia  of  the  conjunctiva  and  nasal  catarrh,  which 
are  frequently  the  initial  accompaniments  of  measles,  and 
the  existence  of  an  epidemic,  still  are  at  this  stage  valuable 
indications  in  favour  of  this  eruptive  fever. 

If  croup  complicates  measles,  it  supervenes  usually  after 
the  eruption  or  during  the  development  of  the  latter.  With 
the  laryngeal  mirror  diagnosis  is  easily  confirmed.  Those 
varieties  of  pseudo-membranous  laryngitis  may  also  separately 
develop  without  affecting  the  pharyngeal  cavity,  the  whole 
lesion  occupying  the  larynx  even  to  the  trachea. 


384  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

The  appearance  of  the  rubeolar  eruption  enables  us  to  put 
a  true  value  on  the  complications  which  remain  when  the 
latter  have  disappeared. 

Course. — The  modifications  in  the  vocal  mucosa  during 
the  onset  of  the  eruption  may  disappear  when  the  latter 
becomes  generalized.  At  other  times,  on  the  contrary,  each 
congestive  attack  is  followed  by  laryngeal  lesions,  which  must 
be  treated  by  special  means.  The  course  of  the  affection 
depends  on  the  nature  of  the  complications,  its  form,  and 
the  intensity  of  the  rubeolar  epidemic. 

Prognosis  is  usually  benign,  yet  crico-arytenoid  articular 
lesions,  perilaryngeal  abscesses,  gangrene  of  the  mucosa,  and 
simple  inflammatory  or  pseudo-membranous  laryngo-stenosis, 
are  so  many  complications  liable  to  make  prognosis  grave,  as 
they  may  cause  death. 

Treatment  at  the  beginning  may  be  directed  simply  to  the 
measles,  taking  care  to  avoid  prescribing  energetic  counter- 
irritants.  It  will  be  sufficient  to  place  sponges  or  linen 
soaked  in  warm  water  in  front  of  the  neck.  Sinapisms, 
or  even  warm  poultices,  have  a  similar  effect.  If  the  larynx 
is  affected  during  the  course  of  the  rubeolar  eruption,  warm 
inhalations  will  usually  arrest  aggravation  of  the  symptoms. 

If  suffocation  or  graver  complications  are  threatened, 
they  should  be  treated  by  the  usual  means,  remembering 
that  rubeolar  croup  without  alteration  of  the  mucosa  can 
be  easily  arrested  by  intubation  of  the  larynx,  which  may 
equally  be  indicated  in  cases  of  immobility  of  the  vocal 
cords  in  the  mesial  position  through  recurrent  compression. 

If  ulceration  or  œdematous  infiltration — in  a  word,  hyper- 
acute inflammatory  lesions — be  present  in  the  vocal  mucosa, 
rest  of  the  larynx  may  be  assured  more  efficiently  by  trache- 
otomy, and  a  cure  be  facilitated  in  this  way. 

Treatment  should  then  be  directed  to  the  different  morbid 
alterations  as  seen  on  laryngoscopic  examination. 

Typhoid  Laryngitis. 
Typhoid   laryngitis    comprises    complications    capable    of 
affecting  the  vocal  mucosa  during  typhoid  or  typhus  fever. 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     385 

Frequency. — The  laryngeal  complications  of  enteric  fever 
were  little  known  before  the  beginning  of  last  century  (Bayle, 
1808;  Brouillaud  and  Cruveilhier,  1825).  The  most  impor- 
tant works  on  the  question  have  been  those  of  Koch  (1878), 
N.  Blaising  (1880),  Tissier,  etc. 

Authors  who  have  written  on  this  subject  admit,  that 
the  frequency  of  those  morbid  alterations  depends  on  the 
time  and  season  when  epidemics  develop,  and  especially  on 
the  nature  of  the  latter.  Thus  Mollière  observed  (1876) 
numerous  laryngeal  complications  at  Lyons,  while  at  the 
same  time  those  manifestations  were  rare  in  Paris,  where 
the  same  disease  raged. 

Typhoid  laryngitis  is  a  common  occurrence  among  soldiers 
on  campaign,  and  affects  debilitated  subjects.  It  is  better 
known  in  hospital  than  in  private  practice.  The  author 
is  convinced  that  superficial  laryngeal  lesions  would  be 
fairly  frequently  observed  if  systematic  examination  of  the 
pharyngeal  cavity  and  the  larynx  typhoid  patients  were 
practised. 

On  the  other  hand,  we  know  that  many  alterations  of  the 
larynx  apparent  during  life  are  not  observed  on  autopsy 
{e.g.,  cedematous  infiltrations,  superficial  erosions).  The 
statistics  dealing  with  the  frequency  of  this  complication 
are  all  more  or  less  unreliable. 

The  slight  erythematous  forms  are  observed  in  the  second, 
and  especially  in  the  third  week,  while  the  graver  com- 
plications are  met  with  principally  during  convalescence. 

Etiology — Pathogeny. — The  explanation  of  the  appearance 
of  this  laryngitis  may  lie  in  the  nature  of  the  epidemic  germ, 
the  want  of  hygienic  care,  cold,  and  in  the  straining  of  the 
voice  prior  to  the  attack.  Males  seem  to  be  more  predis- 
posed, probably  on  account  of  the  nature  of  their  ordinary 
vocations. 

The  most  conflicting  theories  exist  on  the  pathogenesis 
of  these  laryngeal  lesions.  According  to  Brouillaud  and 
Cruveilhier,  it  is  merely  a  question  of  inflammation  analogous 
to  that  of  the  gums,  tongue,  and  pharyngeal  cavity. 

Rokitansky  admits  a  typhoid  infiltration  in  the  substance 

25 


386  ni  SEA  SE  S  OF  THE  PHARYNX  AND  LARYNX 

of  the  tissues.  '  Typhoid  of  the  larynx,'  says  this  author,  '  is 
in  some  wa}^  the  termination  of  abdominal  typhus.'  The 
position  of  the  lesions  is  against  the  dorsal  decubitus  hypo- 
thesis. The  non-existence  of  closed  follicles,  and  even  the 
rarity  of  ulceration  in  those  portions  of  the  vocal  mucous 
membrane  where  they  are  agglomerated  (ventricles,  vocal 
cords),  are  sufficient  to  oppose  the  analogy  said  to  exist 
between  the  larynx  and  the  intestine  (Wisseman,  Coyne). 

The  microbic  theory  also  has  its  supporters,  and  perhaps 
it  may  be  admitted,  that  the  larynx  does  not  escape  infection 
any  more  than  the  other  organs. 

Symptomatology.  —  Laryngeal  manifestations  of  typhoid 
fever  appear  in  different  forms  :  (i)  erythematous  ;  (2)  diph- 
theritic ;  (3)  ulcerative,  which  is  divided  into  primary  necrosis 
and  secondary  or  consecutive  necrosis  ;  (4)  myopathic. 

I.  Erythematous  Form. — Functional  disturbances  of  simple 
acute  catarrhal  laryngitis  are  observed.  A  feeling  of 
smarting  and  dryness  in  the  pharyngeal  cavity  provokes 
difficulty  and  pain  in  swallowing.  The  voice  is  husky  or 
raucous,  coughing  is  absent,  or  if  it  exists  is  dry,  paroxysmal, 
or  spasmodic. 

On  laryngoscopic  examination,  general  desquamation  of 
the  laryngeal  mucosa  is  observed,  mainly  on  the  epiglottis, 
the  aryepiglottic  folds,  the  ventricular  bands,  and  also  on 
the  vocal  cords,  specially  on  their  upper  surface. 

The  whole  superficial  layer  of  the  epithelium  is  destroyed. 
Small  blackish  or  dark  grey  mucous  pellets  are  displaced 
during  the  effort  of  coughing,  and  are  thus  distinguished 
from  erosions  or  even  ulceration.  The  larynx  appears  dry 
and  has  a  varnished-like  appearance,  resembling  the  mucosa 
of  the  nasal  fossae  and  the  pharynx  at  this  stage  of  the  disease. 
Erythematous  laryngitis  usually  supervenes  during  the 
course  of  typhoid  fever  ;  it  corresponds  to  the  catarrhal  form 
of  German  authors,  and  according  to  Lœri  may  occur 
with  hypertrophy  of  the  spleen,  and  with  the  characteristic 
temperature  chart  associated  with  this  infection.  This  com- 
plication is  observed  specially  in  adults,  and  in  really  con- 
firmed forms  of  enteric  fever.     It  is  exceptional  in  children. 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX    387 

2.  Diphtheritic  Form.— This  is  rare.  It  usually  appears  in 
the  third  week,  and  is  characterized  especially  by  the  thin- 
ness of  the  false  membrane,  which  covers  the  vocal  mucosa. 
The  functional  symptoms  resemble  those  of  diphtheria  in 
general;  nevertheless,  as  the  membrane  is  not  much  de- 
veloped, dyspnœa  is  usually  slightly  pronounced.  True 
ulceration  of  the  mucous  membrane  has  been  noted,  as 
occurring  in  consequence  of,  or  during  the  development  of, 
pseudo-membranous  laryngitis. 

Eppinger  is  of  the  opinion  that  these  membranous  layers 
are  not  exudatory  products,  but  are  formed  of  an  epithelium 
metamorphosed  by  necrosis,  with  here  and  there  masses  of 
micrococci.  The  latter,  according  to  this  author,  play  an 
active  part  in  the  production  of  the  ulcerative  process. 
Through  the  successive  necrosis  of  the  different  layers  loss 
of  substance  takes  place,  which  Eppinger  calls  'septic 
ulceration.'  The  latter  may  also  appear  along  with  typhoid 
ulceration. 

3.  Ulcerative  For;;?.— Functional  disturbances  depend  on 
the  nature  and  extent  of  this  complication.  Sometimes 
palpation  at  the  level  of  the  larynx  is  painful,  while  in  other 
cases  no  pain  exists. 

The  modification  of  the  voice  varies  according  to  the 
position  and  extent  of  the  ulceration.  If  this  attacks  the 
posterior  part  of  the  larynx  or  the  lateral  portions  (ven- 
tricular bands,  cords,  subglottic  region,  etc.),  huskiness, 
raucous  hoarseness,  and  even  complete  aphonia,  are  observed'. 
Respiratory  disturbances  may  be  slight  or  wanting. 
Dyspnœa  may  be  considerable,  and  accompanied  with  attacks 
of  suffocation,  if  rapid  oedema  of  the  aryepiglottic  folds 
suddenly  obstructs  the  entrance  of  the  air  tract.  At  other 
times  tumefaction  or  abscesses  of  the  arytenoid  region  pro- 
duce respiratory  stenosis,  either  by  infiltration  or  by  immo- 
bility of  the  cords  through  crico-arytenoid  arthritis. 

The  character  of  the  cough  changes  with  that  of  the  voice. 
Expectoration  is  variable,  according  to  the  extent  and  depth 
of  the  ulceration,  usually  mucous,  and  sometimes  not  very 
abundant.     It  is  often  purulent,  streaked  with  blood,  even 

25—2 


388  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

sanguinolent,  and  contains  débris  of  necrosed  cartilages  or 
sphacelated  mucosa.  In  this  case  the  breath  is  fetid,  and 
even  ulcerating  crypts  may  actually  be  seen. 

At  the  beginning  laryngoscopic  examination  reveals 
simple  erosions  on  the  epiglottis  or  posterior  region.  They 
are  rounded,  oval,  or  longitudinal,  irregular,  with  flaccid, 
fringed,  thick,  and  infiltrated  edges.  Soon  afterwards  those 
small  ulcerations  extend  and  form  true  craters,  greyish,  dull, 
with  anfractuous  and  sharply-defined  edges.  The  base  of 
the  ulcer  is  almost  always  covered  with  whitish  grey  detritus, 
presenting  blackish  spots  at  some  points,  which  are  indicative 
of  necrosis  of  the  subjacent  cartilage. 

Œdema  of  the  neighbouring  parts  is  always  considerable. 
It  occupies,  as  a  rule,  the  aryepiglottic  folds,  particularly  the 
region  which  corresponds  to  the  crico-arytenoid  articulation, 
the  ventricular  bands,  or  even  the  epiglottis  and  the  subglottic 
region.  Abscesses  in  the  substance  of  the  vocal  mucosa  are 
sometimes  observed.  They  are  deep  and  anfractuous,  and 
at  their  base  the  cricoid,  thyroid,  and  other  cartilages  are 
more  or  less  altered  by  caries  or  necrosis. 

The  parts  of  the  laryngeal  framework  affected  by  necrosis 
are,  in  order  of  frequency,  the  cricoid,  the  arytenoid,  and 
lastly  the  thyroid  and  the  epiglottis. 

The  profound  alterations,  of  which  laryngeal  stenosis  is  the 
result,  usually  appear  during  convalescence.  In  grave  cases 
external  palpation  reveals  the  existence  of  a  thickening  of  the 
framework  of  the  larynx,  with  small  bosses  indicating  the 
modifications  undergone  by  its  fibro-cartilage  (perichondritis). 

External  fistulse  communicating  with  an  inflamed  or 
necrosed  cartilage  may  even  be  produced. 

4.  Myopathic  Form. — This  is  usually  manifested  during 
convalescence  from  typhoid  fever,  or  even  after  recovery. 
It  consists  of  muscular  disturbances,  or  even  of  definite 
paralysis,  through  atrophy  or  degeneration  of  one  or  more 
groups  of  the  laryngeal  muscles.  These  tropho-neurotic 
lesions  only  affect  isolated  muscles  or  those  on  one  side.  It 
is  rare  to  see  the  disturbances  extend  simultaneously  to  the 
whole  larynx.     Nevertheless,   the  author  has  observed  the 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     389 

case  of  a  young  man  who,  as  a  result  of  typhoid,  was  seized 
with  paralysis  that  seemed  to  attack  all  the  laryngeal 
muscles.  The  cords  appeared  flexible  and  relaxed  in  the 
cadaveric  position,  yet  an  alarming  laryngo-stenosis  existed, 
which  necessitated  tracheotomy. 

The  functional  disturbances  of  this  complication  vary 
according  to  the  muscles  paralyzed.  If  the  thyro-arytenoidei 
or  the  constrictors  are  affected,  the  timbre  of  the  voice  is 
deeply  changed,  but  in  the  case  of  the  posterior  crico- 
arytenoidei,  respiration  will  be  interfered  with,  and  the  timbre 
of  the  voice  only  slightly  altered. 

Course,  Duration,  Progress. — The  course  of  typhoid  laryngitis 
and  its  duration  vary  according  to  its  nature  and  gravity. 
The  erythematous  form  ordinarily  disappears  with  the 
general  malady  causing  it. 

The  diphtheritic  form  develops  in  a  different  way,  accord- 
ing to  the  intensity  of  the  exudative  process  and  the  type  of 
the  typhoid  fever  with  which  it  is  associated. 

The  course  of  the  ulcerative  laryngitis  cannot  be  deter- 
mined. It  depends  on  the  nature  of  the  general  infection 
of  the  patient,  and  on  its  extent,  whether  superficial  or  deep. 
Cario-necrotic  laryngitis  is  almost  always  accompanied 
by  œdema  and  phlegmon,  sometimes  by  gangrene.  When 
recovery  takes  place,  laryngeal  stenosis  follows  from  crico- 
arytenoid ankylosis,  perichondritis,  or  diffuse  infiltration  of 
the  larynx. 

The  myopathic  form  is  generally  of  long  duration.  It  is 
months  before  the  paralyzed  muscles  resume  their  functions, 
and  they  may  remain  weak  for  a  long  time. 

Diagnosis  is  sometimes  easy,  but  in  many  cases  it  is  almost 
impossible  on  account  of  the  swelling  of  the  affected  parts. 
When  vocal  disturbances,  dysphagia,  or  certain  respiratory 
difficulties  are  observed  during  typhoid  fever,  attention 
should  be  directed  to  the  larynx.  Direct  examination  should 
then  be  practised  to  obtain  a  complete  diagnosis  of  the 
case.  This  is  usually  easily  performed,  as  the  mucous 
membrane  of  the  pharynx  is  less  sensitive  than  usual. 

Prognosis  is  very  variable,  being  wholly  subordinate  to  the 


390  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

gravity  of  the  infection  producing  the  laryngeal  complica- 
tion, and  to  the  nature  even  of  the  latter. 

Treatment  presents  serious  difficulties.  At  first  it  should 
be  prophylactic.  Sudden  chills  should  be  avoided,  and 
huskiness  and  other  vocal  disturbances  watched  with  care. 
As  the  treatment  by  cold  baths  is  so  much  in  vogue,  it  is 
necessary  to  ascertain  if  the  patient  suffers  from  a  laryngeal 
affection,  before  undertaking  it. 

In  slight  catarrh,  emollient  and  antiseptic  inhalations  may 
be  prescribed,  such  as  mentholated  solutions  in  a  little  water. 


^  Essence  of  Gaultheria     .. 

15  drops 

11115 

Pulverized  menthol 

.     2  to  3  grammes 

gr.  30  to  45 

Thymol 

I  gramme 

gr-i5 

Balsam  of  Peru 

10  grammes 

5iiss 

Tincture  of  eucalyptus    .. 

•      150 

3V 

A  teaspoonful  in  i  pint  of  more  or  less  warm  water. 

Those    inhalations    are    beneficial.      Alkaline    mentholated 
gargles  may  also  be  used  in  superficial  forms. 

If  intralaryngeal  ulceration  is  present,  sprays  of  carbolic 
acid,  benzoate,  borate  or  salicylate  of  soda,  chloral  hydrate, 
or  bromide  of  potassium,  may  be  useful.  The  following  is 
specially  recommended  : 

^  Benzoate  of  soda  ] 
Salicylate  of  soda  f 
Chloral  hydrate 
Glycerine  | 

Peppermint  water  j 
Water 

Aceto-tartrate  of  aluminium  is  an  excellent  substitute  for 
benzoate  of  soda,  using  half  the  quantity.  The  same  drugs 
may  be  used  in  the  form  of  washes  or  gargles  if  the  typhoid 
patient  cannot  use  sprays. 

In  cases  of  abscess,  intervention  through  the  natural 
passages  is  preferable,  if  possible. 

Tracheotomy  on  the  trachea  itself,  and  not  in  the  crico- 


aa  6 

g' 

rammes 

aa 

gr.  90 

3 

55 

gr.  45 
3xi 

ââ  50 

55 

3xii 

400 

J5 

,^xiv 

DISEASES  AND  TRAUMATISMS  OF  THE  LARYXX     391 

thyroid  space,  is  the  sole  treatment  in  cases  of  cedematous 
infiltration,  with  or  ^^•ithout  ulceration.  Koch  has  already 
insisted  in  his  work  on  typhoid  laryngitis  on  the  necessity  of 
opening  the  air  tract  below  the  cricoid,  because  the  latter  and 
the  first  ring  of  the  trachea  are  often  affected  with  necrosis. 
The  operation  should  be  slowly  performed,  layer  by  layer, 
and  the  trachea  incised  carefully,  so  as  to  avoid  misadventure. 
-The  canula  should  be  removed  when  the  larynx  has  resumed 
its  normal  shape  and  the  patient  is  better.  If  laryngeal 
stenosis  exists,  treatment  should  be  carried  out  as  indicated 
above. 

Scarlatinal  Laryngitis. 

Secondary  diphtheria  is  the  laryngeal  complication  of  this 
eruptive  fever.  Certain  epidemics  of  scarlatina — and,  in  fact, 
of  all  eruptive  fevers — are  more  fatal  than  usual,  and  present 
in  their  course  laryngo- tracheal  complications.  Although 
false  membranes  are  found  post-mortem  in  subjects  who  have 
succumbed  to  scarlatina  with  concomitant  laryngitis,  it  does 
not  follow  that  there  was  true  diphtheria  of  the  larynx. 
There  have  been  observed  on  the  larynx  ulceration  and 
necrosis  of  the  cartilages,  with  perichondritis  and  all  the 
symptoms  accompanying  these  lesions.  The  pseudo-mem- 
branous exudation  is  here  secondary.  It  is  found  in  most 
of  the  ulcerative  inflammatory  affections  of  the  pharyngeal 
cavity  and  the  larynx.  In  a  general  way  scarlatina  occurs 
as  an  inflammator}"  laryngitis,  with  infiltration  of  the  glottic 
and  subglottic  mucosa,  accompanied  by  pseudo-membranous 
exudation,  extending  to  the  trachea  and  even  to  the  bronchi, 
sometimes  in  a  true  ulcerative  form.  This  variety  of  laryn- 
gitis is  characterized,  not  only  by  œdematous  infiltration  of 
all  the  parts  of  the  pharynx,  but  specially  b}'  more  or  less 
deep  ulceration,  sometimes  reaching  the  cartilage.  The 
latter  is  attacked  by  perichondritis,  and  is  sometimes  even 
necrosed. 

Local  treatment  varies  from  simple  inhalations,  warm 
fomentations,  injections  of  serum,  etc.,  to  intubation  and 
tracheotomy. 


392  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

Small-pox  (Variola). 

Laryngeal  complications  of  small-pox  appear  at  two  different 
stages  of  the  disease.  In  the  first  period  they  consist  of  more 
or  less  abundant  though  discrete  pustules  of  the  laryngeal 
mucosa,  while  at  a  later  stage  the  more  profound  alterations 
consist  of  cedematous  infiltration  and  ulceration.  The  larynx, 
in  contradistinction  to  that  observed  in  measles,  frequently 
remains  intact  during  the  prodromal  stage  of  the  disease, 
it  being  usually  affected  between  the  third  and  sixth  day, 
\vhen  the  cutaneous  eruption  appears.  Variola  of  the  larynx 
is  very  frequent.  It  exists  in  all  fatal  cases  of  small-pox 
(Riihle  and  Eppinger). 

Pathological  Anatomy. — Authors  who  have  practised  laryn- 
goscopy of  variolous  subjects  have  for  long  debated,  whether 
the  lesions  seen  directl}'  with  the  mirror  were  true  small-pox 
pustules  or  pseudo-pustules.  It  is  manifest,  that  the  eruption 
cannot  show  in  the  larynx  all  the  characteristics  of  cutaneous 
lesions.  The  incessant  motion  of  this  organ  and  its  moist 
condition  rapidly  bring  about  the  rupture  of  the  pustule. 

Desquamation  of  the  cylindrical  epithelial  cells  is  produced 
by  the  suppuration.  An  extensive  serous  infiltration  may  also 
occur  on  the  aryepiglottic  folds  and  the  subglottic  mucosa. 

A  little  later  on  true  ulceration  is  met  with  in  some  cases. 
It  is  discrete  in  other  cases,  or  the  edges  of  the  ulcers  may 
meet,  so  as  to  give  the  laryngeal  mucosa  a  crater -like 
appearance. 

Hsemorrhage  is  sometimes  observed  in  the  pustules,  or  in 
the  submucous  tissue  (hsemorrhagic  form). 

At  a  more  advanced  stage,  the  ulceration — at  first  super- 
ficial—  reaches  the  perichondrium  and  incites  inflamma- 
tion there.  This  perichondritis  (Eppinger)  follows  either 
septic  abscesses  on  the  surface  or  a  diffuse  inflammation  of 
the  submucous  tissue,  almost  resembling  the  primary  form. 

Large  gangrenous  abscesses  then  appear,  accompanied  by 
necrosis  of  the  cartilages,  which  are  partially  or  totally 
eliminated.  Ankylosis,  cicatricial  stenosis,  etc.,  result,  even 
when  the  patient  is  cured  of  the  foregoing  acute  complications. 


DISEASES  AXD  TRAUMATISMS  OF  THE  LARYXX     393 

Syinpîoius  vary  according  to  the  site  and  nature  of  the 
lesion.  In  cases  of  epiglottic  or  arytenoid  pustular  erup- 
tions the  principal  symptom  is  a  more  or  less  acute  pain  on 
deglutition.  This  pain  is  also  very  pronounced  in  cases  of 
perichondritis  or  extensive  ulceration.  External  palpation  is 
painful,  if  the  morbid  changes  have  invaded  the  thyroid  peri- 
chondrium. Vocal  disturbances  are  the  more  pronounced 
as  the  lesions  are  deeper  (vocal  cords,  etc.).  They  vary  with 
the  nature,  form,  and  the  extent  of  the  local  manifestation. 

The  case  of  respiration  is  strictly  proportionate  to  the 
degree  of  patency  of  the  glottic  orifice.  If  there  exists  in- 
flammatory swelling  or  serous  effusion  sufficient  to  block  the 
orifice  of  the  air  tract,  fits  of  suffocation  may  supervene. 
This  symptom  is  seen  in  a  very  marked  form  in  necrosis  of 
the  cricoid,  in  consequence  of  the  collapse  of  the  laryngeal 
framework,  or  at  least  the  partial  or  total  immobility  of  the 
crico-arytenoid  articulation. 

Paresis  or  even  paralysis,  occurring  in  certain  cases,  is 
the  result  (Ruhle)  of  the  invasion  of  the  muscles  by  the 
cedematous  process. 

The  author  thinks,  that  the  causes  of  immobility  of  the 
vocal  cords  are  more  complex,  for  muscular  disturbances 
may  result  from  peripheral  neuritis  or  crico-arytenoid 
arthritis. 

There  is  met  with  on  laryngoscopic  examination  a  shght 
redness  of  the  mucosa,  which  at  the  outset  appears  some- 
what swollen  and  covered  with  more  or  less  thick  mucus. 
During  the  eruptive  stage  pustules  may  be  noticed  under  the 
epithelial  la3-er,  but  most  frequently  the  surface  of  the  mucosa 
is  irregular  and  ulcerated  in  places. 

Later  on  true  ulceration,  with  small  haemorrhages  in  the 
submucosa,  is  perceived,  whose  extent  and  locahty  may  be 
determined  by  the  mirror. 

Course,  Duration,  and  Termination. — The  course  varies  ac- 
cording as  we  are  dealing  with  pustules,  abscess,  ulceration, 
or  necrosis. 

The  pustules  may  be  very  discrete,  suppurate  moderately, 
then  cicatrize  rapidly,  leaving  only  a  small  depression. 


394  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

On  the  contrary,  if  laryngeal  complication  (œdema, 
abscess,  ulceration,  perichondritis,  etc.)  supervenes  during 
convalescence,  it  outlasts  the  variola  and  terminates  in  a 
different  way,  according  to  the  intensity  of  the  local  infectious 
process  and  its  diffusion. 

The  course  of  the  disease  may  be  extraordinarily  variable 
— depending  on  the  virulence  of  the  epidemic,  the  infection, 
and  the  soil  on  which  it  has  developed. 

Diagnosis  is  easy,  from  the  existence  of  the  general  eruptive 
malady.  Its  location  and  extent  are  determined  by  laryn- 
goscopic  examination. 

Prognosis  is  usually  grave,  for  the  existence  of  laryngeal 
complications  in  variola  always  indicates  a  grave  infection, 
capable  of  spreading  to  the  deep  respiratory  organs.  Ecchy- 
moses of  the  laryngeal  mucosa  are  also  serious.  They  occur 
in  hsemorrhagic  variola,  which  in  itself  is  very  grave. 

Death  may  occur  abruptly  from  the  very  abundant  and 
rapid  serous  effusion  of  the  aryepiglottic  folds  (Trousseau). 

Prognosis  is  based  on  the  general  condition  of  the  patient, 
the  prevalent  epidemic,  and  the  laryngoscopic  appearances. 
Great  reserve  must  be  shown,  even  in  slight  forms,  as  to  the 
possible  termination. 

Treatment.  —  In  benign  cases  expectant  treatment  is 
sufficient.  The  employment  of  warm  inhalations,  to  favour 
the  evacuation  of  pus  outwards,  is  recommended. 

If  deep  abscesses  exist,  they  should  be  treated  like  ordinary 
purulent  collections  in  the  larynx.  Should  the  œdema  be 
considerable  and  grave,  local  sprays  of  adrenalin  and  cocaine, 
or,  better  still,  scarification  or  incision  of  the  infiltrated 
mucosa,  may  be  carried  out.  Tracheotomy  is  performed  in 
preference  to  intubation,  as  the  latter  gives  bad  results,  as  soon 
as  suffocative  symptoms  appear,  and  should  be  low  enough 
to  avoid  the  cricoid  ring,  for  the  first  ring  is  often  affected. 
Here,  more  than  ever,  the  tissues  situate  in  front  of  the 
trachea  should  be  incised  slowly,  and  the  position  where  the 
opening  is  to  be  made  clearly  defined,  to  enable  the  canula  to 
be  placed  in  the  midst  of  healthy  cartilages. 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     395 

Erysipelatous   Laryngitis. 

That  erysipelas  affects  the  mucosa  of  the  air  tract  has  been 
long  known. 

Etiology  and  Pathogeny. — While  the  etiology  of  laryngeal 
erysipelas  is  still  obscure,  its  pathology  is  more  explicable. 
There  is  no  reason  why  the  larynx  should  escape  the  usual 
causes  of  septic  inoculation.  The  mucosa,  however,  being 
less  exposed  than  the  external  integument,  is  on  that  account 
less  frequently  attacked.  Erysipelas  is  due  to  infection,  the 
streptococcus  penetrating  from  the  periphery  downwards 
(secondary),  or  vice  versa  (primary). 

Symptoms. — Symptoms  vary  according  to  the  intensity  of 
the  affection.  Three  forms  are  recognized  :  (i)  erythematous  ; 
(2)  phlyctenular  ;  (3)  gangrenous. 

1.  Erythematous  Form. — Functional  symptoms  consist  in 
slight  pain  on  deglutition,  a  burning  sensation  in  the  pharyn- 
geal cavity,  with  more  or  less  huskiness. 

Examination  of  the  larynx  reveals  diffuse  redness,  with 
variable  swelling  of  the  epiglottis,  or  its  folds,  and  sometimes 
of  the  cords  and  the  ventricular  bands. 

2.  Phlyctenular  Form. — The  functional  symptoms  of  this 
form,  slightly  more  marked  than  in  the  preceding,  are  those 
of  œdematous  laryngitis.  The  respiratory  disturbances  often 
necessitate  rapid  and  energetic  intervention. 

On  laryngoscopic  examination,  swelling  is  seen,  resembling 
acute  œdema  of  the  aryepiglottic  folds.  Massei  is  of  the 
opinion  that  this  is  a  primary  erysipelas  of  the  larynx. 
Frequently  at  the  level  of  the  affected  parts  small  superficial 
phlyctenulae  may  be  present;  which  sometimes  pass  un- 
perceived.  In  this  form  the  swelling  not  only  attacks  the 
epiglottis  and  its  folds,  but  the  whole  vocal  mucosa,  often 
the  subglottic  region  and  the  trachea,  a  fact  which  explains 
the  dyspnœic  disturbances  observable  in  patients  affected 
with  this  variety  of  diffuse  infection. 

3.  Gangrenous  Form. — The  symptoms  resemble  those  of 
submucous  laryngitis,  or  primary  infectious  phlegmon  of  the 
larynx  (Senator).     It  is  characterized,  not  only  by  a  profound 


396 


DISEASES  OF  THE  PHARYXX  AND  LARYNX 


alteration  of  the  mucosa,  but  also  of  the  cartilages  of  the 
larynx. 

The  general  symptoms  are  usually  characterized  by  violent 
shivering,  with  fever  (39^  to  41'  C),  great  depression,  malaise, 
vomiting,  etc.  Soon  afterwards  burning  sensations  appear 
in  the  pharyngeal  cavity,  then  pain  on  deglutition,  huski- 
ness,  laboured  and  stertorous  breathing,  and  the  whole 
features  of  a  characteristic  serious  lesion  of  the  vocal  mucosa. 
It  must  be  remembered,  however,  that  glandular  involvement 


Fig.  210. — Gocgcenheim's  Antero-Posterior  Cutting  Forceps. 

The  Author's  pattern  is  furnished  with  lateral  movement. 

is  usually  absent  if  the  larynx  alone  is  affected  and  the 
pharyngeal  cavity  free. 

Adenitis,  if  present,  will  appear  in  the  glands  situate  in 
front  of  the  lar}- nx. 

Course,  Duration,  and  Termination. — The  appearance  of  the 
disease  is  usually  rapid,  although  it  may  occur  by  onsets,  as 
in  erysipelas  in  general.  Its  course  is  progressive,  so  that  in 
a  few  hours  the  disturbances  may  attain  to  a  remarkable 
intensity.  The  duration  depends  on  the  nature  of  the 
infectious  process.  The  erythematous  form  has  a  short 
duration,  while  the  phlyctenular  and  the  gangrenous  last 
for  several  davs,  and  end  either  in  an  abscess  or  a  diffuse 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     397 

phlegmon,  with  elimination  of  the  necrosed  cartilages  or  the 
fragments  of  sphacelated  mucosa,  or  by  asphyxia  and  rapid 
death,  through  suffocation  or  cachexia,  or  finally  by  abate- 
ment and  cure,  with  or  without  consecutive  laryngo-stenosis. 

Prognosis  is  always  grave.  It  depends  on  the  extent, 
rapidity,  and  specially  on  the  form,  of  the  laryngeal  ery- 
sipelas. 

Diagnosis  is  usually  easy.  The  intensity  of  the  general 
and  functional  symptoms  and  the  redness  of  the  affected 
parts,  extending  as  a  rule  to  the  pharynx,  with  diffuse 
tumefaction,  admit  of  primary  erysipelas  being  distinguished 
from  simple  primary  acute  oedema  of  the  larynx.  Secondary 
erysipelas,  coming  through  propagation  of  cutaneous  lesions, 
can  hardly  be  confused  with  another  affection  of  the  larynx. 

Acute  œdema,  terminating  in  a  phlegmon,  or  the  existence 
of  an  abscess  or  gangrenous  phlegmon  of  the  larynx,  always 
suggests  erysipelas  rather  than  a  simple  œdema,  the  course 
of  the  latter  being  generally  ephemeral. 

Treatment  consists  in  the  administration  of  purgatives, 
preferably  saline.  Injections  of  antistreptococcic  or  of 
physiological  serum  help  to  maintain  and  restore  strength, 
and  to  facilitate  expectoration.  Locally,  hot  fomenta- 
tions applied  to  the  neck,  sedative  inhalations,  carbohc 
sprays  or  gargles  or  other  antiseptics,  or,  better  still,  with 
oxygenated  water  (i  :  12),  should  be  employed.  Finally, 
tracheotomy  may  be  necessar}^  It  must,  however,  be  con- 
fessed that  those  therapeutic  means  are  frequently  un- 
successful. 

If  acute  œdematous  infiltration  or  pus  appears,  it  may  be 
treated  as  an  œdematous  laryngitis. 

Rheumatic  Arthritis  of  the  Larynx. 

Rheumatic  laryngeal  affections,  although  not  rare,  are  still 
but  little  known.  They  often  pass  unperceived,  or  the  lesions 
observed  are  assigned  to  other  causes.  Isolated  cases  of 
crico- arytenoid  arthritis  due  to  rheumatism  have  been 
recorded  (Deshousses,  i860;  Lacoarret,  i8gi). 

Rheumatic  arthritis  appears  simultaneously  with  an  attack 


398  DISEASES  OF  THE  PHARYNX  AND  LARYNX 

of  articular  rheumatism,  or  follows  it,  thus  suggesting  the 
diagnosis  of  the  laryngeal  affection.  The  author  has  even 
seen  it  exist  primarily  with  the  symptorns  of  a  simple  acute 
inflammation  due  to  cold. 

I.  Crico-arytenoid  Arthritis. — The  chief  symptom  is 
pain,  frequently  spontaneous,  intensified  by  the  passage  of 
food,  and  even  on  phonation  causing  phonophobia.  Pressure 
at  the  level  of  the  affected  articulation  (crico-arytenoid  or 
crico- thyroid)  is  extremely  painful.  The  side  of  the  neck 
may  be  swollen,  and  some  authors  (Griinwald,  Newcomb) 
have  recorded  a  sort  of  crepitation  perceptible  to  the  hand 
when  placed  on  the  neck  of  the  patient,  particularly  during 
deglutition. 

Respiration  is  generally  free  when  the  arthritis  is  not 
bilateral,  and  the  two  vocal  cords  not  immobilized  in  the 
middle  line. 

Laryngoscopic  examination  usually  reveals  redness  of  the 
arytenoid  region,  reaching  slightly  towards  the  corresponding 
epiglottic  fold.  This  region  is  infiltrated,  especially  towards 
the  base  of  the  arytenoid,  and  to  the  inside  of  the  larynx, 
so  to  speak,  on  the  side  of  the  vocal  apophysis.  (The  opposite 
occurs  in  influenzal  arthritis.)  The  corresponding  cord  is,  of 
course,  immobilized  in  the  middle  line,  or  only  very  slightly 
mobile. 

The  lesion,  if  bilateral,  may  be  more  pronounced  on  one 
side  than  on  the  other. 

The  general  symptoms  correspond  to  the  degree  of  the 
infection  producing  the  laryngeal  lesion. 

Diagnosis  is  easy,  if  unilateral  arthritis  coexists  with 
evidences  of  muscular  or  articular  rheumatism  in  other  parts 
of  the  body,  or  if  the  patient  is  undoubtedly  rheumatic. 

In  arthritis  a  frigore  the  infiltration  is  serous  and  diffuse, 
invading  the  aryepiglottic  folds  and  the  epiglottis,  rather  than 
the  arytenoid  region  alone.  In  influenza  the  lesion  is  almost 
always  bilateral,  the  infiltration  affecting  the  oesophagus 
more  than  the  arytenoid.  The  pain  recurs  periodically 
in  the  evening  and  during  the  night,  diminishing,  and  even 
disappearing,  in  the  morning  and  during  the  day. 


DISEASES  AND  TRAUMATISMS  OF  THE  LARYNX     399 

2.  Crico  -  thyroid  Arthritis.  —  The  cricothyroid 
articulations  may  be  affected  separately  (Escat),  and  in  that 
case  aphonia  from  immobility  of  the  affected  region  is  the 
chief  functional  disturbance. 

Palpation  is  painful  at  the  level  of  the  inferior  horns  of  the 
thyroid.  Pain  is  also  produced  by  faradic  excitation  of  the 
crico-thyroid  muscle  (Escat), 

Laryngoscopic  examination  reveals  a  more  or  less  marked 
relaxation  of  the  paresed  cord. 

The  author  has  seen  these  two  forms  of  arthritis  co-exist 
in  the  same  subject  during  an  attack  of  articular  rheumatism, 
which  successively  invaded  most  of  the  large  articulations. 

The  course  of  the  disease  specially  depends  on  the  general 
infection.     Health  is  usually  restored  in  a  few  weeks. 

Escat  admits,  however,  that  the  lesion  may  become  chronic, 
and  produce  through  ankylosis  a  deformity,  which  he  proposes 
to  call  '  nodular  laryngeal  rheumatism.' 

General  treatment  should  consist  in  saline  purgatives,  hot 
drinks,  salicylate  of  soda— 4  to  6  grammes  in  the  twenty-four 
hours,  according  to  the  age  of  the  patient  and  the  degree  of 
infection. 

Locally,  rest  of  the  organ  should  be  prescribed,  the  applica- 
tion of  counter-irritants,  such  as  sinapisms,  methyl  chloride 
(almost  to  the  extent  of  producing  vesication),  methyl  salicy- 
late, or  tincture  of  iodine,  over  which  cotton-wool  is  applied. 
Warm  aromatic  inhalations  (30  grammes  to  i  litre  of 
water),  used  thrice  daily  for  about  five  minutes,  are  also 
excellent  sedatives. 

Rest  in  bed  or  at  least  confinement  to  the  room  is 
indicated.  If  the  affection  is  bilateral,  and  respiratory  dis- 
turbances exist  (noisy  inspiration  and  expiration),  intubation 
or  tracheotomy  should  be  performed. 


INDEX 


Abductors,  paralysis  of,  271 

Semon's  law,  284 
Abscess  of  larynx,  197 

of  lingual  tonsil,  86,  88 

retro-pharyngeal,  128 

tonsillar  and  peritonsillar,  40 
Adductors,  paralysis  of,  290 

spasm  of,  297 
Albuminuria  in  diphtheria,  36 
Aucemia  of  the  larynx,  169 
Anaesthesia  of  the  larynx,  264 

of  the  pharynx,  139 
Angina,  acute  catarrhal,  18 

erythematous,  12 

herpetic,  23 

polymorphic,  13 

pseudo  -  membranous      non- 
diphtheritic,  32 

ulcero-membranous  (Vincent), 
29 
Antitoxin,  Roux's  serum,  38 
Aphonia,  functional,  297 
Auto-laryngoscopy  (Czermack),  155 
Autoscopy  (Kirstein),  154 

B. 

Bacilli,  fusiform,  31 
Klebs-Loeffler,  34 
pseudo-diphtheritic,  34 
tubercle,  54,  236,  257 
Bochdalek's  canal,  93 
Brockaert  on  laryngeal  paralysis, 

285 
Bronchoscopy,  upper  and   lower, 

160 
Bulbar  lesions  producing  laryngeal 

paralysis,  271 
Burns  of  the  larynx,  172 
of  the  pharynx,  121 

C. 

Cadaveric   position  of   the    cords, 

273,  281,  283 


Calculi  of  the  soft  palate,  114 

of  the  tonsils,  53 
Cancer  of  the  larynx,  240,  346 

of  the  pharynx,  114 

of  the  tonsils,  82 
Casper's  handle,  159 
Catarrh,  laryngeal,  acute,  178 
chronic,  201 

pharyngeal,  acute,  18,  122 
chronic,  136 
Chancre  of  the  tonsil,  65 
Children,  examination  of  the  larynx 

in,  154 
papillomata  of  the  larynx  in, 

315,334 
Chorea,  lai^yngeal,  310 
Concretions,     calcareous,    in     the 

tonsil,  49 
Condylomata  of  the  larynx,  208 
Cough,  nervous  laryngeal,  310 

reflex,  307 

spasmodic,  in  tabes,  304 
Cramp,  speakers',  297 
Crises  in  tabes,  304 
Croup,  false,  188 

true,  37 
Cut  throat,  173 
Cysts  of  the  larynx,  318 

of  the  soft  palate,  m 

of  the  tonsils,  81 

D. 

De    Mendoza's   laryngeal  forceps, 

330 
Diphonia,  336 
Diphtheria,  34 

albuminuria  in,  34 
antitoxin,  Roux's,  in,  38 
paralysis  of  soft  palate,  106 
Dysphagia    in   tuberculous    laryn- 
gitis, 226 
pharyngitis,  55 
in  malignant  disease  of  larynx, 
348 


400 


INDEX 


401 


Dyspnœa  in  laryngitis,  184,  igo,  198 
in  laryngeal  paralysis,  280 
syphilis,  208 
tuberculosis,  228 
tumours,  315 

E. 
Earache,  in  cancer  of  the  larvnx, 

348 
of  the  pharynx,  144 
of  the  tonsils,  83 
in  tuberculous  laryngitis,  227 
pharyngitis^SS 
Ecraseur,    galvanic,    in    enlarged 

tonsils,  75 
Electric  light  for  examination  of 

larynx,  152,  160 
Electricity  in  adductor   paralysis, 
296 
in   anaesthesia   of  the   larvnx, 
266 
Endolaryngeal  operations,  327 
Epiglottitis,  182 
Erj'sipelas,  laryngitis  in,  395 
Escat's  tongue-depressor,  155 
Eunuchoid  voice,  299 
Eversion     of     the     ventricle      of 
jSIorgagni,  342 


Fauvel's  laryngeal  forceps,  329 
Foreign  bodies  in  the  larynx,  372 

in  the  pharynx,  138 

in  the  tonsils,  53 
Fossa,  supratonsillar,  7 
Fracture  of  the  laryngeal  cartilages, 

175 
Functional  aphonia,  297 

G. 

Gangrene  of  the  pharynx,  124 
Glands,  enlargement  of,  in  cancer 
of  larynx,  351 
in  cancer  of  pharvnx. 

145 
Glottis,  oedema  of  the,  184,  193 
spasm  of  the,  in  adults,  185 
in  children,  189 
Gluck's   operation  for  extirpation 

of  larynx,  370 
Goitre,  lingual,  97 
Gummata      in     syphilis     of     the 
lar3'nx,  209 
in  syphilis  of  the  pharynx,  68 


H. 

Haemorrhage  after  tonsillotomy,  79 

laryngeal,  171 
Herpes  of  the  pharvnx,  23 
Hering's  treatment  of  tuberculous 

ulcers,  246 
Hoarseness  in  tuberculous  laryn- 
gitis, 226 
Hypersesthesia  of  the  larvnx,  266 
of  the  pharynx,  139 

I. 

Illumination  of  the  larynx,  151 
Image,  laryngoscopic,  156 
Influenza,  laryngitis  in,  192 
Intubation    in    acute    œdematous 
laryngitis,  187 
in  croup,  39 

in  laryngitis  stridulosa,  188 
in  laryngeal  stenosis,  221 
in    spasm    of     the    laryngeal 
muscles,  307 

K. 

IviUian's  method  of  bronchoscopy 

and  tracheoscopy,  160 
Kirstein's  direct  autoscopv,  154 

tongue-depressor,  155 
Klebs-Loeftler  bacillus,  34 
Krause  treatment  of   tuberculosis 

of  the  larynx,  246 
Kronlein  -  Orlow's     operation     in 

malignant  disease  of  the  pharynx, 

146 

L. 

Labio  -  glosso  -  laryngeal    paralysis, 

304 
Lactic  acid  treatment  in  lupus,  259 

in  tuberculosis,  247 
Lacunar  tonsillitis,  25 
Laryngectomy,  366 
Laryngismus  stridulus,  188 
Laryngitis  stridulosa,  300 
Laryngocele,  345 
Larvngo-fissure,  359 
Larynx,  abscess  of  the,  197 

anaemia  of  the,  169 

anaesthesia  of  the,  264 

burns  of  the,  172 

cancer  of  the,  346 

catarrhal  inflammation  of,  178 

changes  at  puberty,  299 

crises  in  tabes,  304 

diphtheria  of  the,  36 


402 


DISEASES  OF  THE  PHARYNX  AND  LARYNX 


Larynx,  electrode,  296 

erysipelas  of  the,  395 

examination  of  the,  151 

foreign  bodies  in  the,  372 

fracture  of  the,  175 

hyperaesthesia  of  the,  266 

innervation  of  the,  270 

intubation  of  the,  39 

leprosy  of  the,  261 

lupus  of  the,  253 

measles  of  the,  381 

neuralgia  of  the,  267 

paralysis  of  the,  270 

paraesthesia  of  the,  268 

phthisis  of  the,  225 

rheumatic  arthritis  of  the,  397 

scarlet  fever  of  the,  391 

spasm  of  the,  297 

stenosis,  216 

syphilis,  207 

typhoid  fever  of  the,  384 

vertigo  of  the,  311 
Leprosy  of  the  larynx,  261 
Lcptotlirix  buccal  is,  52 
Lingual  tonsil,  abscess  of  the,  86,  88 
benign  growths  of  the,  95 
cysts  of  the,  93 
goitre  of  the,  96 
hypertrophy  of  the,  89 
inflammation  of,  86 
varix,  94 
Lupus  of  the  larynx,  253 

of  the  pharynx,  58 

M. 

Malignant  disease  of  the  larynx,  346 
of  the  pharynx,  144 
of  the  soft  palate,  1 14 
of  the  tonsils,  82 

Measles,  laryngitis  in,  381 

Miliary  tuberculosis  of  the  larynx, 

251 
of  the  pharynx,  55 
Morcellement  in  enlarged  tonsils, 

77 
Morgagni,  eversion  of  the  ventricle 

of,  342 
Moure's  curettes,  261 
forceps,  339,  340 
inhaler,  179 
thyrotomy  scissors,  364 

N. 
Nerve -supply    to    the    laryngeal 
muscles,  270 


Nervous  laryngeal  cough,  310 
Neuralgia  of  the  larynx,  267 
Neuro-muscular  affections  of   the 
larynx,  263 

O. 

O'Dwyer's  intubation  tubes,  40 
O'ldimn  albicans,'  122, 

P. 

Pachydermia  of  the  larynx,  202 
Palate,  anatomy  of  the  soft,  i 

calculi  of  the,  114 

defects  of  conformation  of,  99 

haematoma  of  the,  103 

paralysis  of  the,  106 

syphilis  of  the,  104 

tumours,  benign,  of  the,  109 
malignant,  of  the,  114 
Paralysis  of  abductors,  275 

of  adductors,  290 

after  diphtheria,  37  ,    . 

of  ary-arytaenoidei,  292 

bulbar  lesions  producing,  271 

of  crico-thyroid,  276 

of  larynx,  treatment  of,  295 

of   lateral   crico  -  arytaenoidei, 
290 

recurrent,  276 

Semon's  laWj  284 

of  soft  palate,  106 

of  thyro-arytaenoidei,  290 
Paréesthesia  of  the  larynx,  268 

of  the  pharynx,  139 
Pemphigus  of  the  pharynx,  14 
Perichondritis    in    cancer   of    the 
larynx,  352 

in  syphilis  of  the  larynx,  211 

in  tuberculosis  of  the  larynx, 
234 
Périer's    operation   in    extirpation 

of  the  larynx,  368 
Peritonsillar  abscess,  40 
Pharynx,  anatomy  of  the,  8 

burns  of  the,  120 

constriction  of  the  isthmus  of 
the  buccal,  117 

constrictions  of  the  inferior,  148 

defects       of       conformation, 
pharyngocele,  120 

examination  of,  10 

foreign  bodies  in,  138 

gangrene  of  the,  124 

paraesthesia  of  the,  139 

pemphigus  of  the,  14 


INDEX 


403 


Pharynx,  stenosis  of  the,  148 

syphiUs  of  the,  65 

thrush  of  the,  123 

tuberculosis  of  the,  54 

tumours,  benign,  of  the,  142 
mahgnant,  of  the,  144 

vascular  ectasia  of  the,  122 

wounds  of  the,  120 
Pharyngitis,  catarrhal,  acute,  122 
chronic,  136 

sicca,  126 
Phonetary  spasm,  297 
Phthisis,  laryngeal,  225 

pharyngeal,  54 
Puberty,  "changes  in  the  voice  at, 

^*'  R. 

Recurrent  nerve  paralysis,  276 
Retro-pharyngeal  abscess,  128 
Rheumatic  affections  in  larynx,  397 

S. 
Scarlet  fever,  laryngitis  in,  391 
Semon's  law  in  larvngeal  paralysis, 

284 
Singer's  nodules,  335 
Small-pox,  laryngitis  in,  392 
Stenosis  of  larynx,  216 

of  pharynx,  148 
Stroboscopy,  167 
Supratonsillar  fossa,  7 
Syphilis  of  the  larynx,  207 

of  the  soft  palate,  104 

of  the  pharynx,  65 

T. 

Tabes,  larvngeal  lesions  in,  271 
Tampon   canula  (Trendelenburg), 

Thrush  ot  the  pharynx,  123 
Tonsillitis,  acute,  19 

acute  ulcerative  lacunar,  25 

caseous  lacunar,  49 

diphtheritic,  34 


Tonsillitis,  encysted,  50 

pseudo  -  membranous      non- 
diphtheritic,  32 
ulcero-membranous  (A'incent), 
29 
Tonsils,  abscess  of,  acute,  40 
chronic,  48 
anatomy  of  the,  6 
calculus  of  the,  53 
foreign  bodies  of  the,  53 
hypertrophy  of  the,  72 
mycosis  of  the,  52 
tumours,  benign,  of  the,  80 
malignant,  of  the,  82 
Tracheoscopy,   upper   and   lower, 

160 
Tracheotomy  operation  in  cancer, 

356 
Trendelenburg's  canula,  364 
Typhoid,  laryngitis  in,  384 

U. 

Uvula,  defects  of  conformation,  99 
hsematoma  of,  103 
inflammation  of,  uvulitis,  102 
relaxed,  103 
tumours,  109 

V. 

Vagus,  neuritis  in  diphtheria,  273 
Variola,  laryngitis  in,  392 
Varix  at  the  base  of  the  tongue,  94 
Velo-palatine  hemiplegia,  107 

insufhciency,  99 
Ventricle,  eversion  of,  342 
Vertigo,  laryngeal,  311 
Vincent's  angina,  29 
Vocal    cords,    position    of,    in   the 

various      forms      of      laryngeal 

paralysis,  294 

\V. 

Whistler's  ohve-cutting  luryngeal 
dilator,  219 


Rehnan  Limited,  12g  Shafteshiry  Avenue,  W.C. 


B.  S. 


COLUMBIA  UNIVERSITY 

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expiration  of  a  definite  period  after  the  date  of  borrowing, 
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î'our© 
Ei;menta.y  practical  treatise   on 
I    rti  ceases  of  the  phaiyy  and  larynx 


